{ "hospital_name": "Northwestern Medicine Central DuPage Hospital", "last_updated_on": "2026-04-01", "version": "3.0.0", "location_name": [ "Northwestern Medicine Central DuPage Hospital" ], "hospital_address": [ "25 N. Winfield Rd. Winfield, IL 60190" ], "license_information": { "license_number": "0005744", "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": [ "1003864810", "1740230895" ], "standard_charge_information": [ { "description": "1 Stg Dstl Hypospadias Rpr W/Urtp Skin Flaps", "code_information": [ { "code": "CASE-54324", "type": "LOCAL" }, { "code": "54324", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44491.53, "discounted_cash": 31144.07, "payers_information": [ { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 44491.53, "10th_percentile": 44491.53, "90th_percentile": 44491.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 14014.86, "10th_percentile": 14014.86, "90th_percentile": 14014.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 14014.86, "10th_percentile": 14014.86, "90th_percentile": 14014.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 14014.86, "10th_percentile": 14014.86, "90th_percentile": 14014.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 14014.86, "10th_percentile": 14014.86, "90th_percentile": 14014.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 14014.86, "10th_percentile": 14014.86, "90th_percentile": 14014.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 14014.86, "10th_percentile": 14014.86, "90th_percentile": 14014.86, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 13347.47, "10th_percentile": 13347.47, "90th_percentile": 13347.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_percentage": 42.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 19042.39, "10th_percentile": 19042.39, "90th_percentile": 19042.39, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 31.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 13970.32, "10th_percentile": 13970.32, "90th_percentile": 13970.32, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_percentage": 39.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 17598.96, "10th_percentile": 17598.96, "90th_percentile": 17598.96, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 35.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 15572.05, "10th_percentile": 15572.05, "90th_percentile": 15572.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 6362.29, "10th_percentile": 6362.29, "90th_percentile": 6362.29, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 26694.92, "10th_percentile": 26694.92, "90th_percentile": 26694.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 26694.92, "10th_percentile": 26694.92, "90th_percentile": 26694.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 26694.92, "10th_percentile": 26694.92, "90th_percentile": 26694.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 26694.92, "10th_percentile": 26694.92, "90th_percentile": 26694.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 3069.91, "10th_percentile": 3069.91, "90th_percentile": 3069.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 3069.91, "10th_percentile": 3069.91, "90th_percentile": 3069.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 3069.91, "10th_percentile": 3069.91, "90th_percentile": 3069.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_percentage": 41.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 18200.87, "10th_percentile": 18200.87, "90th_percentile": 18200.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 35593.21, "10th_percentile": 35593.21, "90th_percentile": 35593.21, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_percentage": 21.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 9436.04, "10th_percentile": 9436.04, "90th_percentile": 9436.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_percentage": 36.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 40152.59, "10th_percentile": 40152.59, "90th_percentile": 40152.59, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_percentage": 36.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 40152.59, "10th_percentile": 40152.59, "90th_percentile": 40152.59, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 22245.79, "10th_percentile": 22245.79, "90th_percentile": 22245.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 22245.79, "10th_percentile": 22245.79, "90th_percentile": 22245.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 22120.34, "10th_percentile": 22120.34, "90th_percentile": 22120.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 29475.74, "10th_percentile": 29475.74, "90th_percentile": 29475.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 57.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 25538.13, "10th_percentile": 25538.13, "90th_percentile": 25538.13, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 38707.64, "10th_percentile": 38707.64, "90th_percentile": 38707.64, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 34080.53, "10th_percentile": 34080.53, "90th_percentile": 34080.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 28295.37, "10th_percentile": 28295.37, "90th_percentile": 28295.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 35593.21, "10th_percentile": 35593.21, "90th_percentile": 35593.21, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 76.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 34213.99, "10th_percentile": 34213.99, "90th_percentile": 34213.99, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 91.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 40576.26, "10th_percentile": 40576.26, "90th_percentile": 40576.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, supplies, and other services can be included in reimbursement.", "median_amount": 28029.67, "10th_percentile": 28029.67, "90th_percentile": 28029.67, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_percentage": 41.08, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 4045.0, "10th_percentile": 4045.0, "90th_percentile": 4045.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_percentage": 41.08, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 4045.0, "10th_percentile": 4045.0, "90th_percentile": 4045.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_percentage": 93.0, "standard_charge_algorithm": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5116.53, "10th_percentile": 5116.53, "90th_percentile": 5116.53, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price", "median_amount": 5116.53, "10th_percentile": 5116.53, "90th_percentile": 5116.53, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price", "median_amount": 5116.53, "10th_percentile": 5116.53, "90th_percentile": 5116.53, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5116.53, "10th_percentile": 5116.53, "90th_percentile": 5116.53, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price", "median_amount": 5116.53, "10th_percentile": 5116.53, "90th_percentile": 5116.53, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.859733380; Using new claim; Scope: All Financial Classes; Cases: 7; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $44,491.53 @ 11.5% = $5,116.53 due to $0.00 Claim Price" } ] } ] }, { "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": 47.42, "maximum": 687.3, "setting": "outpatient", "gross_charge": 687.3, "discounted_cash": 481.11, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 98.28, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 674.73, "10th_percentile": 674.73, "90th_percentile": 674.73, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 459.8, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5270.68, "10th_percentile": 5270.68, "90th_percentile": 5270.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 283.85, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.53, "10th_percentile": 768.53, "90th_percentile": 768.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 76.29, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 76.29, "10th_percentile": 76.29, "90th_percentile": 76.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 76.29, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 76.29, "10th_percentile": 76.29, "90th_percentile": 76.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 76.29, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 76.29, "10th_percentile": 76.29, "90th_percentile": 76.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 76.29, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 76.29, "10th_percentile": 76.29, "90th_percentile": 76.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 76.29, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 76.29, "10th_percentile": 76.29, "90th_percentile": 76.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 76.29, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 76.29, "10th_percentile": 76.29, "90th_percentile": 76.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 412.38, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 412.38, "10th_percentile": 412.38, "90th_percentile": 412.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 412.38, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 412.38, "10th_percentile": 412.38, "90th_percentile": 412.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 412.38, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 412.38, "10th_percentile": 412.38, "90th_percentile": 412.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 47.42, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.42, "10th_percentile": 47.42, "90th_percentile": 47.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 47.42, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.42, "10th_percentile": 47.42, "90th_percentile": 47.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 47.42, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.42, "10th_percentile": 47.42, "90th_percentile": 47.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 687.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 687.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 687.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 687.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $687.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $687.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 687.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $687.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $687.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 687.3, "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 $687.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "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 $687.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 687.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 137.46, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 137.46, "10th_percentile": 137.46, "90th_percentile": 137.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 137.46, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 137.46, "10th_percentile": 137.46, "90th_percentile": 137.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 343.65, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 343.65, "10th_percentile": 343.65, "90th_percentile": 343.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 549.84, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 549.84, "10th_percentile": 549.84, "90th_percentile": 549.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 147.08, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 147.08, "10th_percentile": 147.08, "90th_percentile": 147.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 549.84, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 549.84, "10th_percentile": 549.84, "90th_percentile": 549.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 345.02, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.02, "10th_percentile": 345.02, "90th_percentile": 345.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 433.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 433.0, "10th_percentile": 433.0, "90th_percentile": 433.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 526.47, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 526.47, "10th_percentile": 526.47, "90th_percentile": 526.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 528.53, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 528.53, "10th_percentile": 528.53, "90th_percentile": 528.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 626.82, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 626.82, "10th_percentile": 626.82, "90th_percentile": 626.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 597.95, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 597.95, "10th_percentile": 597.95, "90th_percentile": 597.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 412.38, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 412.38, "10th_percentile": 412.38, "90th_percentile": 412.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 394.51, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 394.51, "10th_percentile": 394.51, "90th_percentile": 394.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 441.45, "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": 441.45, "10th_percentile": 441.45, "90th_percentile": 441.45, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 343.65, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 343.65, "10th_percentile": 343.65, "90th_percentile": 343.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 395.88, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.88, "10th_percentile": 395.88, "90th_percentile": 395.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 215.81, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 215.81, "10th_percentile": 215.81, "90th_percentile": 215.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 362.89, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 362.89, "10th_percentile": 362.89, "90th_percentile": 362.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 206.19, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 206.19, "10th_percentile": 206.19, "90th_percentile": 206.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 240.56, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1346.65, "10th_percentile": 1346.65, "90th_percentile": 1346.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 120.96, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.96, "10th_percentile": 120.96, "90th_percentile": 120.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 120.96, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.96, "10th_percentile": 120.96, "90th_percentile": 120.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 282.34, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.34, "10th_percentile": 282.34, "90th_percentile": 282.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 282.34, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.34, "10th_percentile": 282.34, "90th_percentile": 282.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $687.30 @ 11.5% = $79.04 due to $0.00 Claim Price", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $687.30 @ 11.5% = $79.04 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $687.30 @ 11.5% = $79.04 due to $0.00 Claim Price", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $687.30 @ 11.5% = $79.04 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 687.3, "10th_percentile": 687.3, "90th_percentile": 687.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "105MM PRE BENT SPHERX ROD", "code_information": [ { "code": "SUP-307196", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 299.02, "maximum": 4333.69, "setting": "outpatient", "gross_charge": 4333.69, "discounted_cash": 3033.58, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2899.24, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2288.54, "10th_percentile": 2288.54, "90th_percentile": 2288.54, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1789.81, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.16, "10th_percentile": 82.16, "90th_percentile": 82.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2600.21, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2600.21, "10th_percentile": 2600.21, "90th_percentile": 2600.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2600.21, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2600.21, "10th_percentile": 2600.21, "90th_percentile": 2600.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 299.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.02, "10th_percentile": 299.02, "90th_percentile": 299.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 299.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.02, "10th_percentile": 299.02, "90th_percentile": 299.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3466.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3466.95, "10th_percentile": 3466.95, "90th_percentile": 3466.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 2166.85, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2166.85, "10th_percentile": 2166.85, "90th_percentile": 2166.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3770.31, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3770.31, "10th_percentile": 3770.31, "90th_percentile": 3770.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2487.54, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2487.54, "10th_percentile": 2487.54, "90th_percentile": 2487.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 2175.51, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2175.51, "10th_percentile": 2175.51, "90th_percentile": 2175.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 2166.85, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 2166.85, "10th_percentile": 2166.85, "90th_percentile": 2166.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2783.53, "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": 2783.53, "10th_percentile": 2783.53, "90th_percentile": 2783.53, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3952.33, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3952.33, "10th_percentile": 3952.33, "90th_percentile": 3952.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 3332.61, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 3332.61, "10th_percentile": 3332.61, "90th_percentile": 3332.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 927.41, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 927.41, "10th_percentile": 927.41, "90th_percentile": 927.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 3319.61, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 3319.61, "10th_percentile": 3319.61, "90th_percentile": 3319.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2600.21, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2600.21, "10th_percentile": 2600.21, "90th_percentile": 2600.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 3466.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 3466.95, "10th_percentile": 3466.95, "90th_percentile": 3466.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2730.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2730.22, "10th_percentile": 2730.22, "90th_percentile": 2730.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4,333.69 @ 11.5% = $498.37 due to $0.00 Claim Price", "median_amount": 498.37, "10th_percentile": 498.37, "90th_percentile": 498.37, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4,333.69 @ 11.5% = $498.37 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 619.72, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 48.93, "10th_percentile": 48.93, "90th_percentile": 48.93, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4,333.69 @ 11.5% = $498.37 due to $0.00 Claim Price", "median_amount": 498.37, "10th_percentile": 498.37, "90th_percentile": 498.37, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $4,333.69 @ 11.5% = $498.37 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2288.19, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2288.19, "10th_percentile": 2288.19, "90th_percentile": 2288.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1516.79, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1516.79, "10th_percentile": 1516.79, "90th_percentile": 1516.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1300.11, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1300.11, "10th_percentile": 1300.11, "90th_percentile": 1300.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1360.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1360.78, "10th_percentile": 1360.78, "90th_percentile": 1360.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2496.21, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2496.21, "10th_percentile": 2496.21, "90th_percentile": 2496.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 762.73, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 762.73, "10th_percentile": 762.73, "90th_percentile": 762.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 762.73, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 762.73, "10th_percentile": 762.73, "90th_percentile": 762.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1780.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1780.28, "10th_percentile": 1780.28, "90th_percentile": 1780.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1780.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1780.28, "10th_percentile": 1780.28, "90th_percentile": 1780.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2600.21, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2600.21, "10th_percentile": 2600.21, "90th_percentile": 2600.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 299.02, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 299.02, "10th_percentile": 299.02, "90th_percentile": 299.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,333.69 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,333.69 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4333.69, "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 $4,333.69 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "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 $4,333.69 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,333.69 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,333.69 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4333.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 4333.69, "10th_percentile": 4333.69, "90th_percentile": 4333.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 481.04, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 481.04, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 481.04, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 481.04, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 481.04, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 481.04, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "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": 4.94, "maximum": 34.58, "setting": "outpatient", "gross_charge": 34.58, "discounted_cash": 24.21, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 20.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 15.51, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.51, "10th_percentile": 15.51, "90th_percentile": 15.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 14.21, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.21, "10th_percentile": 14.21, "90th_percentile": 14.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 6.92, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 14.19, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.19, "10th_percentile": 14.19, "90th_percentile": 14.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 34.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $34.58 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $34.58 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 34.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $34.58 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $34.58 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 34.58, "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 $34.58 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "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 $34.58 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 34.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 13.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.16, "10th_percentile": 13.16, "90th_percentile": 13.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 13.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.16, "10th_percentile": 13.16, "90th_percentile": 13.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 18.26, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.26, "10th_percentile": 18.26, "90th_percentile": 18.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 19.92, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.92, "10th_percentile": 19.92, "90th_percentile": 19.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 10.86, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 10.86, "10th_percentile": 10.86, "90th_percentile": 10.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 10.37, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "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 OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.94, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 4.94, "10th_percentile": 4.94, "90th_percentile": 4.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 12.1, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 12.1, "10th_percentile": 12.1, "90th_percentile": 12.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 34.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 34.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 34.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 17.36, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.36, "10th_percentile": 17.36, "90th_percentile": 17.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 26.59, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 26.59, "10th_percentile": 26.59, "90th_percentile": 26.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 22.21, "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": 22.21, "10th_percentile": 22.21, "90th_percentile": 22.21, "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": "CDH UHC HMO/PPO", "standard_charge_dollar": 23.13, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.13, "10th_percentile": 23.13, "90th_percentile": 23.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 31.54, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 31.54, "10th_percentile": 31.54, "90th_percentile": 31.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 27.66, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 27.66, "10th_percentile": 27.66, "90th_percentile": 27.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 14.21, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.21, "10th_percentile": 14.21, "90th_percentile": 14.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 19.85, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 19.85, "10th_percentile": 19.85, "90th_percentile": 19.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 17.29, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.29, "10th_percentile": 17.29, "90th_percentile": 17.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 27.66, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 27.66, "10th_percentile": 27.66, "90th_percentile": 27.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 14.19, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.19, "10th_percentile": 14.19, "90th_percentile": 14.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 6.92, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 7.4, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.4, "10th_percentile": 7.4, "90th_percentile": 7.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 30.08, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 30.08, "10th_percentile": 30.08, "90th_percentile": 30.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 14.28, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.28, "10th_percentile": 14.28, "90th_percentile": 14.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 26.49, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 26.49, "10th_percentile": 26.49, "90th_percentile": 26.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 17.29, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 17.29, "10th_percentile": 17.29, "90th_percentile": 17.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 21.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 21.79, "10th_percentile": 21.79, "90th_percentile": 21.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 15.51, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.51, "10th_percentile": 15.51, "90th_percentile": 15.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 20.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 20.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 13.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.16, "10th_percentile": 13.16, "90th_percentile": 13.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 13.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.16, "10th_percentile": 13.16, "90th_percentile": 13.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.58, "10th_percentile": 34.58, "90th_percentile": 34.58, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "3.2MM TITANIUM ROD 240MM", "code_information": [ { "code": "SUP-58639", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 158.86, "maximum": 2302.28, "setting": "outpatient", "gross_charge": 2302.28, "discounted_cash": 1611.6, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1540.23, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5270.68, "10th_percentile": 5270.68, "90th_percentile": 5270.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 950.84, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.53, "10th_percentile": 768.53, "90th_percentile": 768.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1381.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1381.37, "10th_percentile": 1381.37, "90th_percentile": 1381.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1381.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1381.37, "10th_percentile": 1381.37, "90th_percentile": 1381.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 158.86, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.86, "10th_percentile": 158.86, "90th_percentile": 158.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 158.86, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.86, "10th_percentile": 158.86, "90th_percentile": 158.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 158.86, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.86, "10th_percentile": 158.86, "90th_percentile": 158.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,302.28 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,302.28 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,302.28 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,302.28 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,302.28 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,302.28 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2302.28, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 405.2, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 405.2, "10th_percentile": 405.2, "90th_percentile": 405.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1151.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1151.14, "10th_percentile": 1151.14, "90th_percentile": 1151.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1478.75, "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": 1478.75, "10th_percentile": 1478.75, "90th_percentile": 1478.75, "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": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1841.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1841.82, "10th_percentile": 1841.82, "90th_percentile": 1841.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1763.55, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1763.55, "10th_percentile": 1763.55, "90th_percentile": 1763.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1321.51, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1321.51, "10th_percentile": 1321.51, "90th_percentile": 1321.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1381.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1381.37, "10th_percentile": 1381.37, "90th_percentile": 1381.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2002.98, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2002.98, "10th_percentile": 2002.98, "90th_percentile": 2002.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1841.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1841.82, "10th_percentile": 1841.82, "90th_percentile": 1841.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 492.69, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 492.69, "10th_percentile": 492.69, "90th_percentile": 492.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1450.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1450.44, "10th_percentile": 1450.44, "90th_percentile": 1450.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1770.45, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1770.45, "10th_percentile": 1770.45, "90th_percentile": 1770.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1155.74, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1155.74, "10th_percentile": 1155.74, "90th_percentile": 1155.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1151.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1151.14, "10th_percentile": 1151.14, "90th_percentile": 1151.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 2099.68, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2099.68, "10th_percentile": 2099.68, "90th_percentile": 2099.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 460.46, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 460.46, "10th_percentile": 460.46, "90th_percentile": 460.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 460.46, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 460.46, "10th_percentile": 460.46, "90th_percentile": 460.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,302.28 @ 11.5% = $264.76 due to $0.00 Claim Price", "median_amount": 264.76, "10th_percentile": 264.76, "90th_percentile": 264.76, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,302.28 @ 11.5% = $264.76 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 329.23, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 674.73, "10th_percentile": 674.73, "90th_percentile": 674.73, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 255.55, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 255.55, "10th_percentile": 255.55, "90th_percentile": 255.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 255.55, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 255.55, "10th_percentile": 255.55, "90th_percentile": 255.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 255.55, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 255.55, "10th_percentile": 255.55, "90th_percentile": 255.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 255.55, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 255.55, "10th_percentile": 255.55, "90th_percentile": 255.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 255.55, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 255.55, "10th_percentile": 255.55, "90th_percentile": 255.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 255.55, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 255.55, "10th_percentile": 255.55, "90th_percentile": 255.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1381.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1381.37, "10th_percentile": 1381.37, "90th_percentile": 1381.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1326.11, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1326.11, "10th_percentile": 1326.11, "90th_percentile": 1326.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 722.92, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 722.92, "10th_percentile": 722.92, "90th_percentile": 722.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1215.6, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1215.6, "10th_percentile": 1215.6, "90th_percentile": 1215.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 690.68, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 690.68, "10th_percentile": 690.68, "90th_percentile": 690.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 805.8, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1346.65, "10th_percentile": 1346.65, "90th_percentile": 1346.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 405.2, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 405.2, "10th_percentile": 405.2, "90th_percentile": 405.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 945.78, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.78, "10th_percentile": 945.78, "90th_percentile": 945.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 945.78, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.78, "10th_percentile": 945.78, "90th_percentile": 945.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,302.28 @ 11.5% = $264.76 due to $0.00 Claim Price", "median_amount": 264.76, "10th_percentile": 264.76, "90th_percentile": 264.76, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,302.28 @ 11.5% = $264.76 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2302.28, "10th_percentile": 2302.28, "90th_percentile": 2302.28, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 2229.28, "maximum": 32308.47, "setting": "outpatient", "gross_charge": 32308.47, "discounted_cash": 22615.93, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3586.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3586.24, "10th_percentile": 3586.24, "90th_percentile": 3586.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3586.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3586.24, "10th_percentile": 3586.24, "90th_percentile": 3586.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3586.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3586.24, "10th_percentile": 3586.24, "90th_percentile": 3586.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3586.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3586.24, "10th_percentile": 3586.24, "90th_percentile": 3586.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3586.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3586.24, "10th_percentile": 3586.24, "90th_percentile": 3586.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3586.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3586.24, "10th_percentile": 3586.24, "90th_percentile": 3586.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 32308.47, "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 $32,308.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "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 $32,308.47 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $32,308.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $32,308.47 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $32,308.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $32,308.47 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 32308.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 16154.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16154.24, "10th_percentile": 16154.24, "90th_percentile": 16154.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 25846.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 25846.78, "10th_percentile": 25846.78, "90th_percentile": 25846.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2229.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2229.28, "10th_percentile": 2229.28, "90th_percentile": 2229.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2229.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2229.28, "10th_percentile": 2229.28, "90th_percentile": 2229.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2229.28, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2229.28, "10th_percentile": 2229.28, "90th_percentile": 2229.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 19385.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 19385.08, "10th_percentile": 19385.08, "90th_percentile": 19385.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 19385.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 19385.08, "10th_percentile": 19385.08, "90th_percentile": 19385.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 24748.29, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 24748.29, "10th_percentile": 24748.29, "90th_percentile": 24748.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 24845.21, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 24845.21, "10th_percentile": 24845.21, "90th_percentile": 24845.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 20354.34, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 20354.34, "10th_percentile": 20354.34, "90th_percentile": 20354.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 19385.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 19385.08, "10th_percentile": 19385.08, "90th_percentile": 19385.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 28108.37, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 28108.37, "10th_percentile": 28108.37, "90th_percentile": 28108.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 18545.06, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 18545.06, "10th_percentile": 18545.06, "90th_percentile": 18545.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5686.29, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5686.29, "10th_percentile": 5686.29, "90th_percentile": 5686.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 13272.32, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13272.32, "10th_percentile": 13272.32, "90th_percentile": 13272.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 13343.4, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2347.45, "10th_percentile": 2347.45, "90th_percentile": 2347.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 6914.01, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6914.01, "10th_percentile": 6914.01, "90th_percentile": 6914.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 25846.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 25846.78, "10th_percentile": 25846.78, "90th_percentile": 25846.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 29465.32, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 29465.32, "10th_percentile": 29465.32, "90th_percentile": 29465.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 16154.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 16154.24, "10th_percentile": 16154.24, "90th_percentile": 16154.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 20751.73, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 20751.73, "10th_percentile": 20751.73, "90th_percentile": 20751.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 21614.37, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21614.37, "10th_percentile": 21614.37, "90th_percentile": 21614.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 16218.85, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16218.85, "10th_percentile": 16218.85, "90th_percentile": 16218.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 9692.54, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 9692.54, "10th_percentile": 9692.54, "90th_percentile": 9692.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 17058.87, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17058.87, "10th_percentile": 17058.87, "90th_percentile": 17058.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 10144.86, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 10144.86, "10th_percentile": 10144.86, "90th_percentile": 10144.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 18609.68, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18609.68, "10th_percentile": 18609.68, "90th_percentile": 18609.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 11307.96, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 11307.96, "10th_percentile": 11307.96, "90th_percentile": 11307.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 4620.11, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 4620.11, "10th_percentile": 4620.11, "90th_percentile": 4620.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5686.29, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5686.29, "10th_percentile": 5686.29, "90th_percentile": 5686.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 13272.32, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13272.32, "10th_percentile": 13272.32, "90th_percentile": 13272.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 19385.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 19385.08, "10th_percentile": 19385.08, "90th_percentile": 19385.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 32308.47, "10th_percentile": 32308.47, "90th_percentile": 32308.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $32,308.47 @ 11.5% = $3,715.47 due to $0.00 Claim Price", "median_amount": 3715.47, "10th_percentile": 3715.47, "90th_percentile": 3715.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $32,308.47 @ 11.5% = $3,715.47 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $32,308.47 @ 11.5% = $3,715.47 due to $0.00 Claim Price", "median_amount": 3715.47, "10th_percentile": 3715.47, "90th_percentile": 3715.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $32,308.47 @ 11.5% = $3,715.47 due to $0.00 Claim Price" } ] } ] }, { "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": 244.18, "maximum": 3538.79, "setting": "outpatient", "gross_charge": 3538.79, "discounted_cash": 2477.15, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 506.05, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 674.73, "10th_percentile": 674.73, "90th_percentile": 674.73, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1461.52, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.53, "10th_percentile": 768.53, "90th_percentile": 768.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2367.45, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5270.68, "10th_percentile": 5270.68, "90th_percentile": 5270.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 392.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 392.81, "10th_percentile": 392.81, "90th_percentile": 392.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 392.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 392.81, "10th_percentile": 392.81, "90th_percentile": 392.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 392.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 392.81, "10th_percentile": 392.81, "90th_percentile": 392.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 392.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 392.81, "10th_percentile": 392.81, "90th_percentile": 392.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 392.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 392.81, "10th_percentile": 392.81, "90th_percentile": 392.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 392.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 392.81, "10th_percentile": 392.81, "90th_percentile": 392.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 244.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.18, "10th_percentile": 244.18, "90th_percentile": 244.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 244.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.18, "10th_percentile": 244.18, "90th_percentile": 244.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 244.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.18, "10th_percentile": 244.18, "90th_percentile": 244.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2123.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2123.27, "10th_percentile": 2123.27, "90th_percentile": 2123.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2123.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2123.27, "10th_percentile": 2123.27, "90th_percentile": 2123.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2123.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2123.27, "10th_percentile": 2123.27, "90th_percentile": 2123.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3538.79, "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 $3,538.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "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 $3,538.79 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3538.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,538.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,538.79 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3538.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,538.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,538.79 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3538.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3538.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3538.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3538.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1453.73, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1453.73, "10th_percentile": 1453.73, "90th_percentile": 1453.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1453.73, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1453.73, "10th_percentile": 1453.73, "90th_percentile": 1453.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 707.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 707.76, "10th_percentile": 707.76, "90th_percentile": 707.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 707.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 707.76, "10th_percentile": 707.76, "90th_percentile": 707.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2123.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2123.27, "10th_percentile": 2123.27, "90th_percentile": 2123.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1769.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1769.4, "10th_percentile": 1769.4, "90th_percentile": 1769.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2831.03, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2831.03, "10th_percentile": 2831.03, "90th_percentile": 2831.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2710.71, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2710.71, "10th_percentile": 2710.71, "90th_percentile": 2710.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3078.75, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3078.75, "10th_percentile": 3078.75, "90th_percentile": 3078.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2031.27, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2031.27, "10th_percentile": 2031.27, "90th_percentile": 2031.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1769.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1769.4, "10th_percentile": 1769.4, "90th_percentile": 1769.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2831.03, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2831.03, "10th_percentile": 2831.03, "90th_percentile": 2831.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3227.38, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3227.38, "10th_percentile": 3227.38, "90th_percentile": 3227.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1776.47, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1776.47, "10th_percentile": 1776.47, "90th_percentile": 1776.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 757.3, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 757.3, "10th_percentile": 757.3, "90th_percentile": 757.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2229.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2229.44, "10th_percentile": 2229.44, "90th_percentile": 2229.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2272.96, "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": 2272.96, "10th_percentile": 2272.96, "90th_percentile": 2272.96, "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": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2721.33, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2721.33, "10th_percentile": 2721.33, "90th_percentile": 2721.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1111.18, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1111.18, "10th_percentile": 1111.18, "90th_percentile": 1111.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1868.48, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1868.48, "10th_percentile": 1868.48, "90th_percentile": 1868.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1061.64, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1061.64, "10th_percentile": 1061.64, "90th_percentile": 1061.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2038.34, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2038.34, "10th_percentile": 2038.34, "90th_percentile": 2038.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1238.58, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1346.65, "10th_percentile": 1346.65, "90th_percentile": 1346.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 622.83, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 622.83, "10th_percentile": 622.83, "90th_percentile": 622.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 622.83, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 622.83, "10th_percentile": 622.83, "90th_percentile": 622.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3538.79, "10th_percentile": 3538.79, "90th_percentile": 3538.79, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,538.79 @ 11.5% = $406.96 due to $0.00 Claim Price", "median_amount": 406.96, "10th_percentile": 406.96, "90th_percentile": 406.96, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,538.79 @ 11.5% = $406.96 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,538.79 @ 11.5% = $406.96 due to $0.00 Claim Price", "median_amount": 406.96, "10th_percentile": 406.96, "90th_percentile": 406.96, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,538.79 @ 11.5% = $406.96 due to $0.00 Claim Price" } ] } ] }, { "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": 422.43, "maximum": 6122.22, "setting": "outpatient", "gross_charge": 6122.22, "discounted_cash": 4285.55, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3526.4, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3526.4, "10th_percentile": 3526.4, "90th_percentile": 3526.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3232.53, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3232.53, "10th_percentile": 3232.53, "90th_percentile": 3232.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1922.38, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1922.38, "10th_percentile": 1922.38, "90th_percentile": 1922.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1836.67, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1836.67, "10th_percentile": 1836.67, "90th_percentile": 1836.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 875.48, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 674.73, "10th_percentile": 674.73, "90th_percentile": 674.73, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 4095.77, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5270.68, "10th_percentile": 5270.68, "90th_percentile": 5270.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2528.48, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.53, "10th_percentile": 768.53, "90th_percentile": 768.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 679.57, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 679.57, "10th_percentile": 679.57, "90th_percentile": 679.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 679.57, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 679.57, "10th_percentile": 679.57, "90th_percentile": 679.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 679.57, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 679.57, "10th_percentile": 679.57, "90th_percentile": 679.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 679.57, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 679.57, "10th_percentile": 679.57, "90th_percentile": 679.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 679.57, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 679.57, "10th_percentile": 679.57, "90th_percentile": 679.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 679.57, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 679.57, "10th_percentile": 679.57, "90th_percentile": 679.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3673.33, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3673.33, "10th_percentile": 3673.33, "90th_percentile": 3673.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3673.33, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3673.33, "10th_percentile": 3673.33, "90th_percentile": 3673.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3673.33, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3673.33, "10th_percentile": 3673.33, "90th_percentile": 3673.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 422.43, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 422.43, "10th_percentile": 422.43, "90th_percentile": 422.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 422.43, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 422.43, "10th_percentile": 422.43, "90th_percentile": 422.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 422.43, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 422.43, "10th_percentile": 422.43, "90th_percentile": 422.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6122.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 6122.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6122.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 6122.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,122.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,122.22 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 6122.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,122.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,122.22 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6122.22, "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 $6,122.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "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 $6,122.22 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 6122.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1224.44, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1224.44, "10th_percentile": 1224.44, "90th_percentile": 1224.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1224.44, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1224.44, "10th_percentile": 1224.44, "90th_percentile": 1224.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 3061.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3061.11, "10th_percentile": 3061.11, "90th_percentile": 3061.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4897.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4897.78, "10th_percentile": 4897.78, "90th_percentile": 4897.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1310.16, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1310.16, "10th_percentile": 1310.16, "90th_percentile": 1310.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 4897.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 4897.78, "10th_percentile": 4897.78, "90th_percentile": 4897.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 3073.35, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3073.35, "10th_percentile": 3073.35, "90th_percentile": 3073.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3857.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3857.0, "10th_percentile": 3857.0, "90th_percentile": 3857.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 4689.62, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 4689.62, "10th_percentile": 4689.62, "90th_percentile": 4689.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4707.99, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4707.99, "10th_percentile": 4707.99, "90th_percentile": 4707.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 5583.46, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 5583.46, "10th_percentile": 5583.46, "90th_percentile": 5583.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5326.33, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5326.33, "10th_percentile": 5326.33, "90th_percentile": 5326.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3673.33, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3673.33, "10th_percentile": 3673.33, "90th_percentile": 3673.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3514.15, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3514.15, "10th_percentile": 3514.15, "90th_percentile": 3514.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 3932.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3932.3, "10th_percentile": 3932.3, "90th_percentile": 3932.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 3061.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 3061.11, "10th_percentile": 3061.11, "90th_percentile": 3061.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2142.78, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1346.65, "10th_percentile": 1346.65, "90th_percentile": 1346.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1077.51, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1077.51, "10th_percentile": 1077.51, "90th_percentile": 1077.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1077.51, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1077.51, "10th_percentile": 1077.51, "90th_percentile": 1077.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2515.01, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2515.01, "10th_percentile": 2515.01, "90th_percentile": 2515.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2515.01, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2515.01, "10th_percentile": 2515.01, "90th_percentile": 2515.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,122.22 @ 11.5% = $704.06 due to $0.00 Claim Price", "median_amount": 704.06, "10th_percentile": 704.06, "90th_percentile": 704.06, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,122.22 @ 11.5% = $704.06 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,122.22 @ 11.5% = $704.06 due to $0.00 Claim Price", "median_amount": 704.06, "10th_percentile": 704.06, "90th_percentile": 704.06, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,122.22 @ 11.5% = $704.06 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6122.22, "10th_percentile": 6122.22, "90th_percentile": 6122.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "6F 13CM INTRO SYS W/INFUS SIDE PORT SAFESHEATH II", "code_information": [ { "code": "SUP-358902", "type": "CDM" }, { "code": "C1892", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 63.08, "maximum": 914.21, "setting": "outpatient", "gross_charge": 914.21, "discounted_cash": 639.95, "payers_information": [ { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 457.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.11, "10th_percentile": 457.11, "90th_percentile": 457.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 700.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 700.28, "10th_percentile": 700.28, "90th_percentile": 700.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 195.64, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.64, "10th_percentile": 195.64, "90th_percentile": 195.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 731.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 731.37, "10th_percentile": 731.37, "90th_percentile": 731.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 377.57, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 377.57, "10th_percentile": 377.57, "90th_percentile": 377.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 731.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 731.37, "10th_percentile": 731.37, "90th_percentile": 731.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 703.03, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 703.03, "10th_percentile": 703.03, "90th_percentile": 703.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 833.76, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 833.76, "10th_percentile": 833.76, "90th_percentile": 833.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 457.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 457.11, "10th_percentile": 457.11, "90th_percentile": 457.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 575.95, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 575.95, "10th_percentile": 575.95, "90th_percentile": 575.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 548.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 548.53, "10th_percentile": 548.53, "90th_percentile": 548.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 795.36, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 795.36, "10th_percentile": 795.36, "90th_percentile": 795.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 524.76, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 524.76, "10th_percentile": 524.76, "90th_percentile": 524.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 587.2, "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": 587.2, "10th_percentile": 587.2, "90th_percentile": 587.2, "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": "CDH UHC CORE", "standard_charge_dollar": 458.93, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.93, "10th_percentile": 458.93, "90th_percentile": 458.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 611.61, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 611.61, "10th_percentile": 611.61, "90th_percentile": 611.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 130.73, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 130.73, "10th_percentile": 130.73, "90th_percentile": 130.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 375.56, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 375.56, "10th_percentile": 375.56, "90th_percentile": 375.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 375.56, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 375.56, "10th_percentile": 375.56, "90th_percentile": 375.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 160.9, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.9, "10th_percentile": 160.9, "90th_percentile": 160.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 160.9, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.9, "10th_percentile": 160.9, "90th_percentile": 160.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 63.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.08, "10th_percentile": 63.08, "90th_percentile": 63.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 63.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.08, "10th_percentile": 63.08, "90th_percentile": 63.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 63.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.08, "10th_percentile": 63.08, "90th_percentile": 63.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 548.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 548.53, "10th_percentile": 548.53, "90th_percentile": 548.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 548.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 548.53, "10th_percentile": 548.53, "90th_percentile": 548.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 548.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 548.53, "10th_percentile": 548.53, "90th_percentile": 548.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $914.21 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $914.21 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $914.21 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $914.21 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $914.21 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $914.21 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": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 914.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 101.48, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 101.48, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 101.48, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 101.48, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 101.48, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 101.48, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 101.48, "10th_percentile": 101.48, "90th_percentile": 101.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $914.21 @ 11.5% = $105.13 due to $0.00 Claim Price", "median_amount": 105.13, "10th_percentile": 105.13, "90th_percentile": 105.13, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $914.21 @ 11.5% = $105.13 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $914.21 @ 11.5% = $105.13 due to $0.00 Claim Price", "median_amount": 105.13, "10th_percentile": 105.13, "90th_percentile": 105.13, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $914.21 @ 11.5% = $105.13 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 914.21, "10th_percentile": 914.21, "90th_percentile": 914.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 287.06, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 287.06, "10th_percentile": 287.06, "90th_percentile": 287.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 526.58, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.58, "10th_percentile": 526.58, "90th_percentile": 526.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 274.26, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 274.26, "10th_percentile": 274.26, "90th_percentile": 274.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 319.97, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 319.97, "10th_percentile": 319.97, "90th_percentile": 319.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 482.7, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 482.7, "10th_percentile": 482.7, "90th_percentile": 482.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 32 MG/ML ORAL SUSP", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-181460", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00121-1781-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 9.5, "setting": "outpatient", "gross_charge": 9.5, "discounted_cash": 6.65, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.9, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4.26, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.26, "10th_percentile": 4.26, "90th_percentile": 4.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.9, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.9, "10th_percentile": 1.9, "90th_percentile": 1.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.9, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 9.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 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; 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 9.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 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": "OP Default; 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 9.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 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 Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.36, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 3.33, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2.85, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% 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 Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 5.02, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.02, "10th_percentile": 5.02, "90th_percentile": 5.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2.98, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2.98, "10th_percentile": 2.98, "90th_percentile": 2.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 5.47, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.47, "10th_percentile": 5.47, "90th_percentile": 5.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.9, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.9, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4.26, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.26, "10th_percentile": 4.26, "90th_percentile": 4.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 7.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% 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; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.03, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.03, "10th_percentile": 2.03, "90th_percentile": 2.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 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": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3.92, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 7.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 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": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 7.31, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 7.31, "10th_percentile": 7.31, "90th_percentile": 7.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 8.66, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 8.66, "10th_percentile": 8.66, "90th_percentile": 8.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH 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": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% 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 Services; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 9.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 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": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.9, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.9, "10th_percentile": 1.9, "90th_percentile": 1.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.7, "10th_percentile": 5.7, "90th_percentile": 5.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 8.27, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 8.27, "10th_percentile": 8.27, "90th_percentile": 8.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 5.45, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 5.45, "10th_percentile": 5.45, "90th_percentile": 5.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 6.1, "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": 6.1, "10th_percentile": 6.1, "90th_percentile": 6.1, "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": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4.77, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.77, "10th_percentile": 4.77, "90th_percentile": 4.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 6.36, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.36, "10th_percentile": 6.36, "90th_percentile": 6.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 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 - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "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": "CDH MEDICARE", "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": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "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": "CDH 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": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "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" } ] } ] }, { "description": "ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN", "drug_information": { "unit": 65.0, "type": "ML" }, "code_information": [ { "code": "RX-186132", "type": "CDM" }, { "code": "J0131", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "24201-0100-24", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.2, "maximum": 162.25, "setting": "outpatient", "gross_charge": 162.25, "discounted_cash": 113.57, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.01, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.01, "10th_percentile": 18.01, "90th_percentile": 18.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.01, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.01, "10th_percentile": 18.01, "90th_percentile": 18.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.01, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.01, "10th_percentile": 18.01, "90th_percentile": 18.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.01, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.01, "10th_percentile": 18.01, "90th_percentile": 18.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.01, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.01, "10th_percentile": 18.01, "90th_percentile": 18.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.01, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.01, "10th_percentile": 18.01, "90th_percentile": 18.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 97.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 97.35, "10th_percentile": 97.35, "90th_percentile": 97.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 97.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 97.35, "10th_percentile": 97.35, "90th_percentile": 97.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 97.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 97.35, "10th_percentile": 97.35, "90th_percentile": 97.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 162.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 162.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 162.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 162.25, "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 $162.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "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 $162.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 162.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $162.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $162.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 162.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $162.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $162.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 162.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 11.2, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.2, "10th_percentile": 11.2, "90th_percentile": 11.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 11.2, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.2, "10th_percentile": 11.2, "90th_percentile": 11.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 11.2, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.2, "10th_percentile": 11.2, "90th_percentile": 11.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 28.56, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.56, "10th_percentile": 28.56, "90th_percentile": 28.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 28.56, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.56, "10th_percentile": 28.56, "90th_percentile": 28.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 66.65, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.65, "10th_percentile": 66.65, "90th_percentile": 66.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 66.65, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.65, "10th_percentile": 66.65, "90th_percentile": 66.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 48.68, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 48.68, "10th_percentile": 48.68, "90th_percentile": 48.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 50.95, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 50.95, "10th_percentile": 50.95, "90th_percentile": 50.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 147.97, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 147.97, "10th_percentile": 147.97, "90th_percentile": 147.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 102.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 102.22, "10th_percentile": 102.22, "90th_percentile": 102.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 124.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 124.28, "10th_percentile": 124.28, "90th_percentile": 124.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 81.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 81.13, "10th_percentile": 81.13, "90th_percentile": 81.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 124.77, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 124.77, "10th_percentile": 124.77, "90th_percentile": 124.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 97.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 97.35, "10th_percentile": 97.35, "90th_percentile": 97.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 141.16, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 141.16, "10th_percentile": 141.16, "90th_percentile": 141.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 129.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 129.8, "10th_percentile": 129.8, "90th_percentile": 129.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 129.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 129.8, "10th_percentile": 129.8, "90th_percentile": 129.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 81.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.13, "10th_percentile": 81.13, "90th_percentile": 81.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 93.13, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 93.13, "10th_percentile": 93.13, "90th_percentile": 93.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $162.25 @ 11.5% = $18.66 due to $0.00 Claim Price", "median_amount": 18.66, "10th_percentile": 18.66, "90th_percentile": 18.66, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $162.25 @ 11.5% = $18.66 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $162.25 @ 11.5% = $18.66 due to $0.00 Claim Price", "median_amount": 18.66, "10th_percentile": 18.66, "90th_percentile": 18.66, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $162.25 @ 11.5% = $18.66 due to $0.00 Claim Price" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.99, "10th_percentile": 2.99, "90th_percentile": 2.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 2.99, "10th_percentile": 2.99, "90th_percentile": 2.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.25, "10th_percentile": 162.25, "90th_percentile": 162.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 56.79, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2.73, "10th_percentile": 2.73, "90th_percentile": 2.73, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 23.2, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 0.27, "10th_percentile": 0.27, "90th_percentile": 0.27, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "description": "ACETAZOLAMIDE 125 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-112", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "70756-0720-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.93, "maximum": 13.5, "setting": "outpatient", "gross_charge": 13.5, "discounted_cash": 9.45, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 9.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.03, "10th_percentile": 9.03, "90th_percentile": 9.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 6.78, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.78, "10th_percentile": 6.78, "90th_percentile": 6.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 7.75, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 7.75, "10th_percentile": 7.75, "90th_percentile": 7.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 8.67, "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": 8.67, "10th_percentile": 8.67, "90th_percentile": 8.67, "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": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.14, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.14, "10th_percentile": 5.14, "90th_percentile": 5.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.14, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.14, "10th_percentile": 5.14, "90th_percentile": 5.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.14, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.14, "10th_percentile": 5.14, "90th_percentile": 5.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.14, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.14, "10th_percentile": 5.14, "90th_percentile": 5.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 6.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 12.31, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 12.31, "10th_percentile": 12.31, "90th_percentile": 12.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 11.75, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% 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 Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 10.38, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 10.38, "10th_percentile": 10.38, "90th_percentile": 10.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.89, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.89, "10th_percentile": 2.89, "90th_percentile": 2.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 10.8, "10th_percentile": 10.8, "90th_percentile": 10.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 8.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 8.51, "10th_percentile": 8.51, "90th_percentile": 8.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 10.34, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 10.34, "10th_percentile": 10.34, "90th_percentile": 10.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 5.58, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.58, "10th_percentile": 5.58, "90th_percentile": 5.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 10.8, "10th_percentile": 10.8, "90th_percentile": 10.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 2.7, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 2.7, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 7.78, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.78, "10th_percentile": 7.78, "90th_percentile": 7.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 4.24, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 4.24, "10th_percentile": 4.24, "90th_percentile": 4.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 7.13, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.13, "10th_percentile": 7.13, "90th_percentile": 7.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 4.73, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 4.73, "10th_percentile": 4.73, "90th_percentile": 4.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.93, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1.93, "10th_percentile": 1.93, "90th_percentile": 1.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 4.05, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 4.05, "10th_percentile": 4.05, "90th_percentile": 4.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.54, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.54, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 5.55, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.55, "10th_percentile": 5.55, "90th_percentile": 5.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 5.55, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.55, "10th_percentile": 5.55, "90th_percentile": 5.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 6.06, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.06, "10th_percentile": 6.06, "90th_percentile": 6.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 6.06, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.06, "10th_percentile": 6.06, "90th_percentile": 6.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CC/MCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8277.85, "maximum": 19339.86, "setting": "inpatient", "gross_charge": 29125.74, "discounted_cash": 20388.02, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; 100% Billed", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services - OON; 100% Billed", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 17453.4, "10th_percentile": 17453.4, "90th_percentile": 17453.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 17453.4, "10th_percentile": 17453.4, "90th_percentile": 17453.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; IP Services; 92% Billed", "median_amount": 26761.88, "10th_percentile": 26761.88, "90th_percentile": 26761.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 14544.51, "10th_percentile": 14544.51, "90th_percentile": 14544.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient Services; 63% Billed", "median_amount": 18326.07, "10th_percentile": 18326.07, "90th_percentile": 18326.07, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 75.1% Billed", "median_amount": 21845.84, "10th_percentile": 21845.84, "90th_percentile": 21845.84, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 23271.2, "10th_percentile": 23271.2, "90th_percentile": 23271.2, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 16987.97, "10th_percentile": 16987.97, "90th_percentile": 16987.97, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 25307.43, "10th_percentile": 25307.43, "90th_percentile": 25307.43, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,568.76; Total: $10,568.76", "median_amount": 10568.76, "10th_percentile": 10568.76, "90th_percentile": 10568.76, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,568.76; Total: $10,568.76" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 29089.0, "10th_percentile": 29089.0, "90th_percentile": 29089.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 14544.51, "10th_percentile": 14544.51, "90th_percentile": 14544.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 17453.4, "10th_percentile": 17453.4, "90th_percentile": 17453.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8435.81, "10th_percentile": 8435.81, "90th_percentile": 8435.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; 92% Billed", "median_amount": 26761.88, "10th_percentile": 26761.88, "90th_percentile": 26761.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 32.6% Billed", "median_amount": 9483.01, "10th_percentile": 9483.01, "90th_percentile": 9483.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; 30% Billed", "median_amount": 8726.7, "10th_percentile": 8726.7, "90th_percentile": 8726.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 37% Billed", "median_amount": 10762.93, "10th_percentile": 10762.93, "90th_percentile": 10762.93, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 4159.74, "10th_percentile": 4159.74, "90th_percentile": 4159.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15901.15, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15901.15, "10th_percentile": 15901.15, "90th_percentile": 15901.15, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14587.78, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14587.78, "10th_percentile": 14587.78, "90th_percentile": 14587.78, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15463.75, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15463.75, "10th_percentile": 15463.75, "90th_percentile": 15463.75, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 19339.86, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 29055.5, "10th_percentile": 29055.5, "90th_percentile": 29055.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 12313.53, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 21700.0, "10th_percentile": 21700.0, "90th_percentile": 21700.0, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15463.75, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15463.75, "10th_percentile": 15463.75, "90th_percentile": 15463.75, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15901.15, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15901.15, "10th_percentile": 15901.15, "90th_percentile": 15901.15, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 19339.86, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 29055.5, "10th_percentile": 29055.5, "90th_percentile": 29055.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14587.78, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14587.78, "10th_percentile": 14587.78, "90th_percentile": 14587.78, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 12313.53, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 21700.0, "10th_percentile": 21700.0, "90th_percentile": 21700.0, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,568.76; Total: $10,568.76", "median_amount": 10568.76, "10th_percentile": 10568.76, "90th_percentile": 10568.76, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,568.76; Total: $10,568.76" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $10,568.76; Percentage applied: 97.00%; Total: $10,251.70 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10251.7, "10th_percentile": 10251.7, "90th_percentile": 10251.7, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $10,568.76; Percentage applied: 97.00%; Total: $10,251.70 Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; 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: $8,901.66; Total: $8,901.66 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8901.66, "10th_percentile": 8901.66, "90th_percentile": 8901.66, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.868004571; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; 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: $8,901.66; Total: $8,901.66 Paid at contractual rate, which is 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 MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 14095.04, "maximum": 32930.8, "setting": "inpatient", "gross_charge": 72828.3, "discounted_cash": 50979.81, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; 100% Billed", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services - OON; 100% Billed", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 73137.05, "10th_percentile": 73137.05, "90th_percentile": 73137.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; 30% Billed", "median_amount": 21941.12, "10th_percentile": 21941.12, "90th_percentile": 21941.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 37% Billed", "median_amount": 27060.71, "10th_percentile": 27060.71, "90th_percentile": 27060.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 32.6% Billed", "median_amount": 23842.68, "10th_percentile": 23842.68, "90th_percentile": 23842.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 10458.62, "10th_percentile": 10458.62, "90th_percentile": 10458.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 43882.23, "10th_percentile": 43882.23, "90th_percentile": 43882.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 43882.23, "10th_percentile": 43882.23, "90th_percentile": 43882.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 43882.23, "10th_percentile": 43882.23, "90th_percentile": 43882.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; IP Services; 92% Billed", "median_amount": 67286.09, "10th_percentile": 67286.09, "90th_percentile": 67286.09, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; 92% Billed", "median_amount": 67286.09, "10th_percentile": 67286.09, "90th_percentile": 67286.09, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 36568.53, "10th_percentile": 36568.53, "90th_percentile": 36568.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 36568.53, "10th_percentile": 36568.53, "90th_percentile": 36568.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 63629.23, "10th_percentile": 63629.23, "90th_percentile": 63629.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 42712.06, "10th_percentile": 42712.06, "90th_percentile": 42712.06, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 58509.64, "10th_percentile": 58509.64, "90th_percentile": 58509.64, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21209.74, "10th_percentile": 21209.74, "90th_percentile": 21209.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient Services; 63% Billed", "median_amount": 46076.34, "10th_percentile": 46076.34, "90th_percentile": 46076.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All Inpatient Services; 75.1% Billed", "median_amount": 54925.92, "10th_percentile": 54925.92, "90th_percentile": 54925.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 32930.8, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 32930.8, "10th_percentile": 32930.8, "90th_percentile": 32930.8, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 24839.23, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 24839.23, "10th_percentile": 24839.23, "90th_percentile": 24839.23, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 26330.77, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 26330.77, "10th_percentile": 26330.77, "90th_percentile": 26330.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 20966.77, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 20966.77, "10th_percentile": 20966.77, "90th_percentile": 20966.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 27075.56, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 27075.56, "10th_percentile": 27075.56, "90th_percentile": 27075.56, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 24839.23, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 24839.23, "10th_percentile": 24839.23, "90th_percentile": 24839.23, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 26330.77, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 26330.77, "10th_percentile": 26330.77, "90th_percentile": 26330.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 27075.56, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 27075.56, "10th_percentile": 27075.56, "90th_percentile": 27075.56, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 20966.77, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 20966.77, "10th_percentile": 20966.77, "90th_percentile": 20966.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 32930.8, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 32930.8, "10th_percentile": 32930.8, "90th_percentile": 32930.8, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $16,904.23; Total: $16,904.23", "median_amount": 16904.23, "10th_percentile": 16904.23, "90th_percentile": 16904.23, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $16,904.23; Total: $16,904.23" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $16,904.23; Total: $16,904.23", "median_amount": 16904.23, "10th_percentile": 16904.23, "90th_percentile": 16904.23, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $16,904.23; Total: $16,904.23" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $16,904.23; Percentage applied: 97.00%; Total: $16,397.10 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16397.1, "10th_percentile": 16397.1, "90th_percentile": 16397.1, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $16,904.23; Percentage applied: 97.00%; Total: $16,397.10 Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; 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: $15,157.23; Total: $15,157.23 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15157.23, "10th_percentile": 15157.23, "90th_percentile": 15157.23, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.784763212; Using historical claim(s); Scope: All Financial Classes; Cases: 7; Inpatient; 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: $15,157.23; Total: $15,157.23 Paid at contractual rate, which is 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": 17.73, "maximum": 124.0, "setting": "outpatient", "gross_charge": 124.0, "discounted_cash": 86.8, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 74.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 74.4, "10th_percentile": 74.4, "90th_percentile": 74.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 74.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 74.4, "10th_percentile": 74.4, "90th_percentile": 74.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 74.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 74.4, "10th_percentile": 74.4, "90th_percentile": 74.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 124.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 124.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 124.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 124.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $124.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $124.00 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 124.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $124.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $124.00 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 124.0, "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 $124.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "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 $124.00 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 124.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 124.0, "10th_percentile": 124.0, "90th_percentile": 124.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 17.73, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 17.73, "10th_percentile": 17.73, "90th_percentile": 17.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 43.4, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 43.4, "10th_percentile": 43.4, "90th_percentile": 43.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 37.2, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 37.2, "10th_percentile": 37.2, "90th_percentile": 37.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 38.94, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 38.94, "10th_percentile": 38.94, "90th_percentile": 38.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 74.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 74.4, "10th_percentile": 74.4, "90th_percentile": 74.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 62.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.0, "10th_percentile": 62.0, "90th_percentile": 62.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 95.36, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 95.36, "10th_percentile": 95.36, "90th_percentile": 95.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 71.18, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 71.18, "10th_percentile": 71.18, "90th_percentile": 71.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 94.98, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% 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; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 62.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 62.0, "10th_percentile": 62.0, "90th_percentile": 62.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 113.09, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 113.09, "10th_percentile": 113.09, "90th_percentile": 113.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 107.88, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 107.88, "10th_percentile": 107.88, "90th_percentile": 107.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 99.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 99.2, "10th_percentile": 99.2, "90th_percentile": 99.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 78.12, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 78.12, "10th_percentile": 78.12, "90th_percentile": 78.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 99.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 99.2, "10th_percentile": 99.2, "90th_percentile": 99.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 50.94, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.94, "10th_percentile": 50.94, "90th_percentile": 50.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 50.94, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.94, "10th_percentile": 50.94, "90th_percentile": 50.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": 3106.96, "maximum": 45028.43, "setting": "outpatient", "gross_charge": 45028.43, "discounted_cash": 31519.9, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 27017.06, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 27017.06, "10th_percentile": 27017.06, "90th_percentile": 27017.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 27017.06, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 27017.06, "10th_percentile": 27017.06, "90th_percentile": 27017.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 27017.06, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 27017.06, "10th_percentile": 27017.06, "90th_percentile": 27017.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 45028.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 45028.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 45028.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 45028.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $45,028.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $45,028.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 45028.43, "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 $45,028.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "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 $45,028.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 45028.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $45,028.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $45,028.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 45028.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4998.16, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4998.16, "10th_percentile": 4998.16, "90th_percentile": 4998.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4998.16, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4998.16, "10th_percentile": 4998.16, "90th_percentile": 4998.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4998.16, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4998.16, "10th_percentile": 4998.16, "90th_percentile": 4998.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4998.16, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4998.16, "10th_percentile": 4998.16, "90th_percentile": 4998.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4998.16, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4998.16, "10th_percentile": 4998.16, "90th_percentile": 4998.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4998.16, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4998.16, "10th_percentile": 4998.16, "90th_percentile": 4998.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 23775.01, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23775.01, "10th_percentile": 23775.01, "90th_percentile": 23775.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 14138.93, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 14138.93, "10th_percentile": 14138.93, "90th_percentile": 14138.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 25936.38, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25936.38, "10th_percentile": 25936.38, "90th_percentile": 25936.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 13508.53, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 13508.53, "10th_percentile": 13508.53, "90th_percentile": 13508.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 15759.95, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 15759.95, "10th_percentile": 15759.95, "90th_percentile": 15759.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 6439.07, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 6439.07, "10th_percentile": 6439.07, "90th_percentile": 6439.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 18497.68, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18497.68, "10th_percentile": 18497.68, "90th_percentile": 18497.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 7925.0, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7925.0, "10th_percentile": 7925.0, "90th_percentile": 7925.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3106.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3106.96, "10th_percentile": 3106.96, "90th_percentile": 3106.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 22514.22, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22514.22, "10th_percentile": 22514.22, "90th_percentile": 22514.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 34491.78, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 34491.78, "10th_percentile": 34491.78, "90th_percentile": 34491.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 9636.08, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9636.08, "10th_percentile": 9636.08, "90th_percentile": 9636.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 36022.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 36022.74, "10th_percentile": 36022.74, "90th_percentile": 36022.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 18596.74, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18596.74, "10th_percentile": 18596.74, "90th_percentile": 18596.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 36022.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 36022.74, "10th_percentile": 36022.74, "90th_percentile": 36022.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3106.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3106.96, "10th_percentile": 3106.96, "90th_percentile": 3106.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 34626.86, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 34626.86, "10th_percentile": 34626.86, "90th_percentile": 34626.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3106.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3106.96, "10th_percentile": 3106.96, "90th_percentile": 3106.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 41065.93, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 41065.93, "10th_percentile": 41065.93, "90th_percentile": 41065.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 22514.22, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 22514.22, "10th_percentile": 22514.22, "90th_percentile": 22514.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 28367.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 28367.91, "10th_percentile": 28367.91, "90th_percentile": 28367.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 9005.69, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 9005.69, "10th_percentile": 9005.69, "90th_percentile": 9005.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 27017.06, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 27017.06, "10th_percentile": 27017.06, "90th_percentile": 27017.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 39174.73, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 39174.73, "10th_percentile": 39174.73, "90th_percentile": 39174.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 25846.32, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 25846.32, "10th_percentile": 25846.32, "90th_percentile": 25846.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 28921.76, "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": 28921.76, "10th_percentile": 28921.76, "90th_percentile": 28921.76, "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": "CDH UHC CORE", "standard_charge_dollar": 22604.27, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22604.27, "10th_percentile": 22604.27, "90th_percentile": 22604.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 30124.02, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30124.02, "10th_percentile": 30124.02, "90th_percentile": 30124.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 18497.68, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18497.68, "10th_percentile": 18497.68, "90th_percentile": 18497.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 7925.0, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7925.0, "10th_percentile": 7925.0, "90th_percentile": 7925.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 9005.69, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 9005.69, "10th_percentile": 9005.69, "90th_percentile": 9005.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $45,028.43 @ 11.5% = $5,178.27 due to $0.00 Claim Price", "median_amount": 5178.27, "10th_percentile": 5178.27, "90th_percentile": 5178.27, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $45,028.43 @ 11.5% = $5,178.27 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $45,028.43 @ 11.5% = $5,178.27 due to $0.00 Claim Price", "median_amount": 5178.27, "10th_percentile": 5178.27, "90th_percentile": 5178.27, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $45,028.43 @ 11.5% = $5,178.27 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 45028.43, "10th_percentile": 45028.43, "90th_percentile": 45028.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN", "drug_information": { "unit": 20.0, "type": "ML" }, "code_information": [ { "code": "RX-85043", "type": "CDM" }, { "code": "J0153", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "23155-0258-31", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.96, "maximum": 448.75, "setting": "outpatient", "gross_charge": 448.75, "discounted_cash": 314.12, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $448.75 @ 11.5% = $51.61 due to $0.00 Claim Price", "median_amount": 51.61, "10th_percentile": 51.61, "90th_percentile": 51.61, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $448.75 @ 11.5% = $51.61 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $448.75 @ 11.5% = $51.61 due to $0.00 Claim Price", "median_amount": 51.61, "10th_percentile": 51.61, "90th_percentile": 51.61, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $448.75 @ 11.5% = $51.61 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 49.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 49.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 49.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 49.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 49.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 49.81, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $448.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $448.75 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 448.75, "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 $448.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "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 $448.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $448.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $448.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 448.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 448.75, "10th_percentile": 448.75, "90th_percentile": 448.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 269.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 269.25, "10th_percentile": 269.25, "90th_percentile": 269.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 269.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 269.25, "10th_percentile": 269.25, "90th_percentile": 269.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 269.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 269.25, "10th_percentile": 269.25, "90th_percentile": 269.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 30.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.96, "10th_percentile": 30.96, "90th_percentile": 30.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 30.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.96, "10th_percentile": 30.96, "90th_percentile": 30.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 30.96, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.96, "10th_percentile": 30.96, "90th_percentile": 30.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 78.98, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.98, "10th_percentile": 78.98, "90th_percentile": 78.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 78.98, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.98, "10th_percentile": 78.98, "90th_percentile": 78.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 184.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 184.35, "10th_percentile": 184.35, "90th_percentile": 184.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 184.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 184.35, "10th_percentile": 184.35, "90th_percentile": 184.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 64.17, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 64.17, "10th_percentile": 64.17, "90th_percentile": 64.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 157.06, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 157.06, "10th_percentile": 157.06, "90th_percentile": 157.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 140.91, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 140.91, "10th_percentile": 140.91, "90th_percentile": 140.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 134.63, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 134.63, "10th_percentile": 134.63, "90th_percentile": 134.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 359.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 359.0, "10th_percentile": 359.0, "90th_percentile": 359.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 257.58, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 257.58, "10th_percentile": 257.58, "90th_percentile": 257.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 269.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 269.25, "10th_percentile": 269.25, "90th_percentile": 269.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 345.09, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 345.09, "10th_percentile": 345.09, "90th_percentile": 345.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 224.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 224.38, "10th_percentile": 224.38, "90th_percentile": 224.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 390.41, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 390.41, "10th_percentile": 390.41, "90th_percentile": 390.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 343.74, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 343.74, "10th_percentile": 343.74, "90th_percentile": 343.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 409.26, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 409.26, "10th_percentile": 409.26, "90th_percentile": 409.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 282.71, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 282.71, "10th_percentile": 282.71, "90th_percentile": 282.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 224.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 224.38, "10th_percentile": 224.38, "90th_percentile": 224.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 359.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 359.0, "10th_percentile": 359.0, "90th_percentile": 359.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% 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": 583.27, "maximum": 8453.23, "setting": "outpatient", "gross_charge": 8453.23, "discounted_cash": 5917.26, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1208.81, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,453.23 @ 11.5% = $972.12 due to $0.00 Claim Price", "median_amount": 972.12, "10th_percentile": 972.12, "90th_percentile": 972.12, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,453.23 @ 11.5% = $972.12 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,453.23 @ 11.5% = $972.12 due to $0.00 Claim Price", "median_amount": 972.12, "10th_percentile": 972.12, "90th_percentile": 972.12, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,453.23 @ 11.5% = $972.12 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 938.31, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 938.31, "10th_percentile": 938.31, "90th_percentile": 938.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 938.31, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 938.31, "10th_percentile": 938.31, "90th_percentile": 938.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 938.31, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 938.31, "10th_percentile": 938.31, "90th_percentile": 938.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 938.31, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 938.31, "10th_percentile": 938.31, "90th_percentile": 938.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 938.31, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 938.31, "10th_percentile": 938.31, "90th_percentile": 938.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 938.31, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 938.31, "10th_percentile": 938.31, "90th_percentile": 938.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 583.27, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 583.27, "10th_percentile": 583.27, "90th_percentile": 583.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 583.27, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 583.27, "10th_percentile": 583.27, "90th_percentile": 583.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 583.27, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 583.27, "10th_percentile": 583.27, "90th_percentile": 583.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4243.52, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4243.52, "10th_percentile": 4243.52, "90th_percentile": 4243.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6762.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6762.58, "10th_percentile": 6762.58, "90th_percentile": 6762.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7354.31, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7354.31, "10th_percentile": 7354.31, "90th_percentile": 7354.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5429.51, "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": 5429.51, "10th_percentile": 5429.51, "90th_percentile": 5429.51, "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": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6475.17, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6475.17, "10th_percentile": 6475.17, "90th_percentile": 6475.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6500.53, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6500.53, "10th_percentile": 6500.53, "90th_percentile": 6500.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 4852.15, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 4852.15, "10th_percentile": 4852.15, "90th_percentile": 4852.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4226.62, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4226.62, "10th_percentile": 4226.62, "90th_percentile": 4226.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 7709.35, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7709.35, "10th_percentile": 7709.35, "90th_percentile": 7709.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5071.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5071.94, "10th_percentile": 5071.94, "90th_percentile": 5071.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5325.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5325.53, "10th_percentile": 5325.53, "90th_percentile": 5325.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3472.59, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3472.59, "10th_percentile": 3472.59, "90th_percentile": 3472.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1487.77, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1487.77, "10th_percentile": 1487.77, "90th_percentile": 1487.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4226.62, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4226.62, "10th_percentile": 4226.62, "90th_percentile": 4226.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1690.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1690.65, "10th_percentile": 1690.65, "90th_percentile": 1690.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1808.99, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1808.99, "10th_percentile": 1808.99, "90th_percentile": 1808.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 6762.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 6762.58, "10th_percentile": 6762.58, "90th_percentile": 6762.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 5655.21, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3491.18, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8453.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8453.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8453.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2654.31, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2654.31, "10th_percentile": 2654.31, "90th_percentile": 2654.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2958.63, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2958.63, "10th_percentile": 2958.63, "90th_percentile": 2958.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4463.31, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4463.31, "10th_percentile": 4463.31, "90th_percentile": 4463.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2535.97, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2535.97, "10th_percentile": 2535.97, "90th_percentile": 2535.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 4869.06, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4869.06, "10th_percentile": 4869.06, "90th_percentile": 4869.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5071.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5071.94, "10th_percentile": 5071.94, "90th_percentile": 5071.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5071.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5071.94, "10th_percentile": 5071.94, "90th_percentile": 5071.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1487.77, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1487.77, "10th_percentile": 1487.77, "90th_percentile": 1487.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1690.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1690.65, "10th_percentile": 1690.65, "90th_percentile": 1690.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3472.59, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3472.59, "10th_percentile": 3472.59, "90th_percentile": 3472.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5071.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5071.94, "10th_percentile": 5071.94, "90th_percentile": 5071.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8453.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8453.23, "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 $8,453.23 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "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 $8,453.23 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8453.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,453.23 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,453.23 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8453.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,453.23 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8453.23, "10th_percentile": 8453.23, "90th_percentile": 8453.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,453.23 so that total pmt for all claim lines does not exceed 100% of claim billed amount." } ] } ] }, { "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": 24.56, "maximum": 171.73, "setting": "outpatient", "gross_charge": 171.73, "discounted_cash": 120.21, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 65.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.38, "10th_percentile": 65.38, "90th_percentile": 65.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 65.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.38, "10th_percentile": 65.38, "90th_percentile": 65.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 65.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.38, "10th_percentile": 65.38, "90th_percentile": 65.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 65.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.38, "10th_percentile": 65.38, "90th_percentile": 65.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 103.04, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 103.04, "10th_percentile": 103.04, "90th_percentile": 103.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 103.04, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 103.04, "10th_percentile": 103.04, "90th_percentile": 103.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 103.04, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 103.04, "10th_percentile": 103.04, "90th_percentile": 103.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $171.73 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $171.73 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $171.73 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $171.73 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $171.73 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $171.73 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 171.73, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 53.92, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 53.92, "10th_percentile": 53.92, "90th_percentile": 53.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 98.92, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.92, "10th_percentile": 98.92, "90th_percentile": 98.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 24.56, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 24.56, "10th_percentile": 24.56, "90th_percentile": 24.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 51.52, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 51.52, "10th_percentile": 51.52, "90th_percentile": 51.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 60.11, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 60.11, "10th_percentile": 60.11, "90th_percentile": 60.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 90.67, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.67, "10th_percentile": 90.67, "90th_percentile": 90.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 70.46, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.46, "10th_percentile": 70.46, "90th_percentile": 70.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 70.46, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.46, "10th_percentile": 70.46, "90th_percentile": 70.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 34.35, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 34.35, "10th_percentile": 34.35, "90th_percentile": 34.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 34.35, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 34.35, "10th_percentile": 34.35, "90th_percentile": 34.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 70.55, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.55, "10th_percentile": 70.55, "90th_percentile": 70.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 70.55, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.55, "10th_percentile": 70.55, "90th_percentile": 70.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 77.04, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.04, "10th_percentile": 77.04, "90th_percentile": 77.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 77.04, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.04, "10th_percentile": 77.04, "90th_percentile": 77.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 103.04, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 103.04, "10th_percentile": 103.04, "90th_percentile": 103.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 114.89, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 114.89, "10th_percentile": 114.89, "90th_percentile": 114.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 86.21, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.21, "10th_percentile": 86.21, "90th_percentile": 86.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 156.62, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 156.62, "10th_percentile": 156.62, "90th_percentile": 156.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 110.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 110.3, "10th_percentile": 110.3, "90th_percentile": 110.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 70.92, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.92, "10th_percentile": 70.92, "90th_percentile": 70.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 137.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 137.38, "10th_percentile": 137.38, "90th_percentile": 137.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 85.87, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 85.87, "10th_percentile": 85.87, "90th_percentile": 85.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 36.75, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 98.57, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 98.57, "10th_percentile": 98.57, "90th_percentile": 98.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 149.41, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 149.41, "10th_percentile": 149.41, "90th_percentile": 149.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 108.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 108.19, "10th_percentile": 108.19, "90th_percentile": 108.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 132.06, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 132.06, "10th_percentile": 132.06, "90th_percentile": 132.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 131.55, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 131.55, "10th_percentile": 131.55, "90th_percentile": 131.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 137.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 137.38, "10th_percentile": 137.38, "90th_percentile": 137.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 85.87, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.87, "10th_percentile": 85.87, "90th_percentile": 85.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 171.73, "10th_percentile": 171.73, "90th_percentile": 171.73, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8013.14, "maximum": 18721.41, "setting": "inpatient", "gross_charge": 40410.5, "discounted_cash": 28287.35, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; 100% Billed", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services - OON; 100% Billed", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40413.5, "10th_percentile": 40413.5, "90th_percentile": 40413.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; 30% Billed", "median_amount": 12124.05, "10th_percentile": 12124.05, "90th_percentile": 12124.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All Inpatient Services; 37% Billed", "median_amount": 14953.0, "10th_percentile": 14953.0, "90th_percentile": 14953.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All Inpatient Services; 32.6% Billed", "median_amount": 13174.8, "10th_percentile": 13174.8, "90th_percentile": 13174.8, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 5779.14, "10th_percentile": 5779.14, "90th_percentile": 5779.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 24248.1, "10th_percentile": 24248.1, "90th_percentile": 24248.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 24248.1, "10th_percentile": 24248.1, "90th_percentile": 24248.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 24248.1, "10th_percentile": 24248.1, "90th_percentile": 24248.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; IP Services; 92% Billed", "median_amount": 37180.42, "10th_percentile": 37180.42, "90th_percentile": 37180.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; 92% Billed", "median_amount": 37180.42, "10th_percentile": 37180.42, "90th_percentile": 37180.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 20206.75, "10th_percentile": 20206.75, "90th_percentile": 20206.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 20206.75, "10th_percentile": 20206.75, "90th_percentile": 20206.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 35159.75, "10th_percentile": 35159.75, "90th_percentile": 35159.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 23601.46, "10th_percentile": 23601.46, "90th_percentile": 23601.46, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 32330.8, "10th_percentile": 32330.8, "90th_percentile": 32330.8, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11719.92, "10th_percentile": 11719.92, "90th_percentile": 11719.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient Services; 63% Billed", "median_amount": 25460.51, "10th_percentile": 25460.51, "90th_percentile": 25460.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All Inpatient Services; 75.1% Billed", "median_amount": 30350.54, "10th_percentile": 30350.54, "90th_percentile": 30350.54, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 18721.41, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 18721.41, "10th_percentile": 18721.41, "90th_percentile": 18721.41, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14121.29, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14121.29, "10th_percentile": 14121.29, "90th_percentile": 14121.29, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 14969.25, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14969.25, "10th_percentile": 14969.25, "90th_percentile": 14969.25, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 11919.77, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 11919.77, "10th_percentile": 11919.77, "90th_percentile": 11919.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15392.66, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15392.66, "10th_percentile": 15392.66, "90th_percentile": 15392.66, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14121.29, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14121.29, "10th_percentile": 14121.29, "90th_percentile": 14121.29, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 14969.25, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14969.25, "10th_percentile": 14969.25, "90th_percentile": 14969.25, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15392.66, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15392.66, "10th_percentile": 15392.66, "90th_percentile": 15392.66, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 11919.77, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 11919.77, "10th_percentile": 11919.77, "90th_percentile": 11919.77, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 18721.41, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 18721.41, "10th_percentile": 18721.41, "90th_percentile": 18721.41, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $6,146.46; Total: $6,146.46", "median_amount": 6146.46, "10th_percentile": 6146.46, "90th_percentile": 6146.46, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $6,146.46; Total: $6,146.46" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $6,146.46; Total: $6,146.46", "median_amount": 6146.46, "10th_percentile": 6146.46, "90th_percentile": 6146.46, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $6,146.46; Total: $6,146.46" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Transfer payment: $6,146.46; Percentage applied: 97.00%; Total: $5,962.07 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5962.07, "10th_percentile": 5962.07, "90th_percentile": 5962.07, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Transfer payment: $6,146.46; Percentage applied: 97.00%; Total: $5,962.07 Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Transfer payment: $4,535.13; Total: $4,535.13 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4535.13, "10th_percentile": 4535.13, "90th_percentile": 4535.13, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.853072868; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Transfer payment: $4,535.13; Total: $4,535.13 Paid at contractual rate, which is 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": "AGILE ESO FC 2318MM 9.7CM", "code_information": [ { "code": "SUP-381470", "type": "CDM" }, { "code": "C1874", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1689.45, "maximum": 24484.82, "setting": "outpatient", "gross_charge": 24484.82, "discounted_cash": 17139.37, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2717.82, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2717.82, "10th_percentile": 2717.82, "90th_percentile": 2717.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2717.82, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2717.82, "10th_percentile": 2717.82, "90th_percentile": 2717.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2717.82, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2717.82, "10th_percentile": 2717.82, "90th_percentile": 2717.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2717.82, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2717.82, "10th_percentile": 2717.82, "90th_percentile": 2717.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2717.82, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2717.82, "10th_percentile": 2717.82, "90th_percentile": 2717.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2717.82, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2717.82, "10th_percentile": 2717.82, "90th_percentile": 2717.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,484.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,484.82 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,484.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,484.82 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,484.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,484.82 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 24484.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14690.89, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14690.89, "10th_percentile": 14690.89, "90th_percentile": 14690.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14690.89, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14690.89, "10th_percentile": 14690.89, "90th_percentile": 14690.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14690.89, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14690.89, "10th_percentile": 14690.89, "90th_percentile": 14690.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1689.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1689.45, "10th_percentile": 1689.45, "90th_percentile": 1689.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1689.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1689.45, "10th_percentile": 1689.45, "90th_percentile": 1689.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1689.45, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1689.45, "10th_percentile": 1689.45, "90th_percentile": 1689.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4309.33, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4309.33, "10th_percentile": 4309.33, "90th_percentile": 4309.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4309.33, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4309.33, "10th_percentile": 4309.33, "90th_percentile": 4309.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 8569.69, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 8569.69, "10th_percentile": 8569.69, "90th_percentile": 8569.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 7345.45, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 7345.45, "10th_percentile": 7345.45, "90th_percentile": 7345.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 14103.26, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14103.26, "10th_percentile": 14103.26, "90th_percentile": 14103.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3501.33, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 3501.33, "10th_percentile": 3501.33, "90th_percentile": 3501.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 7688.23, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 7688.23, "10th_percentile": 7688.23, "90th_percentile": 7688.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 12927.98, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12927.98, "10th_percentile": 12927.98, "90th_percentile": 12927.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10058.36, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10058.36, "10th_percentile": 10058.36, "90th_percentile": 10058.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10058.36, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10058.36, "10th_percentile": 10058.36, "90th_percentile": 10058.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 21301.79, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 21301.79, "10th_percentile": 21301.79, "90th_percentile": 21301.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 14054.29, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 14054.29, "10th_percentile": 14054.29, "90th_percentile": 14054.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 15726.6, "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": 15726.6, "10th_percentile": 15726.6, "90th_percentile": 15726.6, "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": "CDH UHC HMO/PPO", "standard_charge_dollar": 16380.34, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16380.34, "10th_percentile": 16380.34, "90th_percentile": 16380.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 18828.83, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 18828.83, "10th_percentile": 18828.83, "90th_percentile": 18828.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 15425.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 15425.44, "10th_percentile": 15425.44, "90th_percentile": 15425.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 10112.23, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2347.45, "10th_percentile": 2347.45, "90th_percentile": 2347.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 12291.38, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12291.38, "10th_percentile": 12291.38, "90th_percentile": 12291.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 14690.89, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 14690.89, "10th_percentile": 14690.89, "90th_percentile": 14690.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 12242.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 12242.41, "10th_percentile": 12242.41, "90th_percentile": 12242.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 22330.16, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 22330.16, "10th_percentile": 22330.16, "90th_percentile": 22330.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 19587.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 19587.86, "10th_percentile": 19587.86, "90th_percentile": 19587.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 12242.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12242.41, "10th_percentile": 12242.41, "90th_percentile": 12242.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 18755.37, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 18755.37, "10th_percentile": 18755.37, "90th_percentile": 18755.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 5239.75, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5239.75, "10th_percentile": 5239.75, "90th_percentile": 5239.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 19587.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 19587.86, "10th_percentile": 19587.86, "90th_percentile": 19587.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,484.82 @ 11.5% = $2,815.75 due to $0.00 Claim Price", "median_amount": 2815.75, "10th_percentile": 2815.75, "90th_percentile": 2815.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,484.82 @ 11.5% = $2,815.75 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,484.82 @ 11.5% = $2,815.75 due to $0.00 Claim Price", "median_amount": 2815.75, "10th_percentile": 2815.75, "90th_percentile": 2815.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,484.82 @ 11.5% = $2,815.75 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24484.82, "10th_percentile": 24484.82, "90th_percentile": 24484.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ALBUMIN, HUMAN 25 % IV SOLP", "drug_information": { "unit": 100.0, "type": "ML" }, "code_information": [ { "code": "RX-8981", "type": "CDM" }, { "code": "P9047", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00944-0493-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 122.72, "maximum": 1778.5, "setting": "outpatient", "gross_charge": 1778.5, "discounted_cash": 1244.95, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 197.41, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 197.41, "10th_percentile": 197.41, "90th_percentile": 197.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 197.41, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 197.41, "10th_percentile": 197.41, "90th_percentile": 197.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 197.41, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 197.41, "10th_percentile": 197.41, "90th_percentile": 197.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 197.41, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 197.41, "10th_percentile": 197.41, "90th_percentile": 197.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 197.41, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 197.41, "10th_percentile": 197.41, "90th_percentile": 197.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 197.41, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 197.41, "10th_percentile": 197.41, "90th_percentile": 197.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1067.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1067.1, "10th_percentile": 1067.1, "90th_percentile": 1067.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1067.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1067.1, "10th_percentile": 1067.1, "90th_percentile": 1067.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1067.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1067.1, "10th_percentile": 1067.1, "90th_percentile": 1067.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,778.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,778.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,778.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,778.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,778.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,778.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1778.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 122.72, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.72, "10th_percentile": 122.72, "90th_percentile": 122.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 122.72, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.72, "10th_percentile": 122.72, "90th_percentile": 122.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 122.72, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.72, "10th_percentile": 122.72, "90th_percentile": 122.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 313.02, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.02, "10th_percentile": 313.02, "90th_percentile": 313.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 313.02, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.02, "10th_percentile": 313.02, "90th_percentile": 313.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 730.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 730.61, "10th_percentile": 730.61, "90th_percentile": 730.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 730.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 730.61, "10th_percentile": 730.61, "90th_percentile": 730.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 254.33, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 254.33, "10th_percentile": 254.33, "90th_percentile": 254.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 533.55, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 533.55, "10th_percentile": 533.55, "90th_percentile": 533.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 558.45, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 558.45, "10th_percentile": 558.45, "90th_percentile": 558.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 622.48, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 622.48, "10th_percentile": 622.48, "90th_percentile": 622.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1621.99, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1621.99, "10th_percentile": 1621.99, "90th_percentile": 1621.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1120.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1120.46, "10th_percentile": 1120.46, "90th_percentile": 1120.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1362.33, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1362.33, "10th_percentile": 1362.33, "90th_percentile": 1362.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 889.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 889.25, "10th_percentile": 889.25, "90th_percentile": 889.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1367.67, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1367.67, "10th_percentile": 1367.67, "90th_percentile": 1367.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1067.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1067.1, "10th_percentile": 1067.1, "90th_percentile": 1067.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1547.3, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1547.3, "10th_percentile": 1547.3, "90th_percentile": 1547.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1422.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1422.8, "10th_percentile": 1422.8, "90th_percentile": 1422.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1422.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1422.8, "10th_percentile": 1422.8, "90th_percentile": 1422.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 889.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 889.25, "10th_percentile": 889.25, "90th_percentile": 889.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1020.86, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1020.86, "10th_percentile": 1020.86, "90th_percentile": 1020.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,778.50 @ 11.5% = $204.53 due to $0.00 Claim Price", "median_amount": 204.53, "10th_percentile": 204.53, "90th_percentile": 204.53, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,778.50 @ 11.5% = $204.53 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,778.50 @ 11.5% = $204.53 due to $0.00 Claim Price", "median_amount": 204.53, "10th_percentile": 204.53, "90th_percentile": 204.53, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,778.50 @ 11.5% = $204.53 due to $0.00 Claim Price" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 106.15, "10th_percentile": 106.15, "90th_percentile": 106.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 106.15, "10th_percentile": 106.15, "90th_percentile": 106.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1778.5, "10th_percentile": 1778.5, "90th_percentile": 1778.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ALBUMIN, HUMAN 25 % IV SOLP", "drug_information": { "unit": 100.0, "type": "ML" }, "code_information": [ { "code": "RX-8981", "type": "CDM" }, { "code": "P9047", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "44206-0251-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 112.76, "maximum": 1634.25, "setting": "outpatient", "gross_charge": 1634.25, "discounted_cash": 1143.97, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 181.4, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.4, "10th_percentile": 181.4, "90th_percentile": 181.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 181.4, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.4, "10th_percentile": 181.4, "90th_percentile": 181.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 181.4, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.4, "10th_percentile": 181.4, "90th_percentile": 181.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 181.4, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.4, "10th_percentile": 181.4, "90th_percentile": 181.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 181.4, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.4, "10th_percentile": 181.4, "90th_percentile": 181.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 181.4, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.4, "10th_percentile": 181.4, "90th_percentile": 181.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 980.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 980.55, "10th_percentile": 980.55, "90th_percentile": 980.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1634.25, "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 $1,634.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "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 $1,634.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1634.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,634.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,634.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1634.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,634.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,634.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1634.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.76, "10th_percentile": 112.76, "90th_percentile": 112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 287.63, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.63, "10th_percentile": 287.63, "90th_percentile": 287.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 287.63, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.63, "10th_percentile": 287.63, "90th_percentile": 287.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 671.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 671.35, "10th_percentile": 671.35, "90th_percentile": 671.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 671.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 671.35, "10th_percentile": 671.35, "90th_percentile": 671.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 233.7, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 233.7, "10th_percentile": 233.7, "90th_percentile": 233.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 490.28, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 490.28, "10th_percentile": 490.28, "90th_percentile": 490.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 513.15, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 513.15, "10th_percentile": 513.15, "90th_percentile": 513.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1251.84, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1251.84, "10th_percentile": 1251.84, "90th_percentile": 1251.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1307.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1307.4, "10th_percentile": 1307.4, "90th_percentile": 1307.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1307.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1307.4, "10th_percentile": 1307.4, "90th_percentile": 1307.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 817.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 817.13, "10th_percentile": 817.13, "90th_percentile": 817.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,634.25 @ 11.5% = $187.94 due to $0.00 Claim Price", "median_amount": 187.94, "10th_percentile": 187.94, "90th_percentile": 187.94, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,634.25 @ 11.5% = $187.94 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 106.15, "10th_percentile": 106.15, "90th_percentile": 106.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 571.99, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 138.83, "10th_percentile": 138.83, "90th_percentile": 138.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 106.15, "10th_percentile": 106.15, "90th_percentile": 106.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,634.25 @ 11.5% = $187.94 due to $0.00 Claim Price", "median_amount": 187.94, "10th_percentile": 187.94, "90th_percentile": 187.94, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,634.25 @ 11.5% = $187.94 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1634.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1634.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1634.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1634.25, "10th_percentile": 1634.25, "90th_percentile": 1634.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 980.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 980.55, "10th_percentile": 980.55, "90th_percentile": 980.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 980.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 980.55, "10th_percentile": 980.55, "90th_percentile": 980.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.76, "10th_percentile": 112.76, "90th_percentile": 112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 112.76, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.76, "10th_percentile": 112.76, "90th_percentile": 112.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 938.06, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 938.06, "10th_percentile": 938.06, "90th_percentile": 938.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 980.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 980.55, "10th_percentile": 980.55, "90th_percentile": 980.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1256.74, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1256.74, "10th_percentile": 1256.74, "90th_percentile": 1256.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1421.8, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1421.8, "10th_percentile": 1421.8, "90th_percentile": 1421.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1490.44, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1490.44, "10th_percentile": 1490.44, "90th_percentile": 1490.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1029.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1029.58, "10th_percentile": 1029.58, "90th_percentile": 1029.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 817.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 817.13, "10th_percentile": 817.13, "90th_percentile": 817.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" } ] } ] }, { "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": "68516-5219-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 111.42, "maximum": 1614.75, "setting": "outpatient", "gross_charge": 1614.75, "discounted_cash": 1130.32, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 507.03, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 507.03, "10th_percentile": 507.03, "90th_percentile": 507.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,614.75 @ 11.5% = $185.70 due to $0.00 Claim Price", "median_amount": 185.7, "10th_percentile": 185.7, "90th_percentile": 185.7, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,614.75 @ 11.5% = $185.70 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,614.75 @ 11.5% = $185.70 due to $0.00 Claim Price", "median_amount": 185.7, "10th_percentile": 185.7, "90th_percentile": 185.7, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,614.75 @ 11.5% = $185.70 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 179.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 179.24, "10th_percentile": 179.24, "90th_percentile": 179.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 179.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 179.24, "10th_percentile": 179.24, "90th_percentile": 179.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 179.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 179.24, "10th_percentile": 179.24, "90th_percentile": 179.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 179.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 179.24, "10th_percentile": 179.24, "90th_percentile": 179.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 179.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 179.24, "10th_percentile": 179.24, "90th_percentile": 179.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 179.24, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 179.24, "10th_percentile": 179.24, "90th_percentile": 179.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,614.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,614.75 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1614.75, "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 $1,614.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "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 $1,614.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,614.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,614.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1614.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1614.75, "10th_percentile": 1614.75, "90th_percentile": 1614.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 968.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 968.85, "10th_percentile": 968.85, "90th_percentile": 968.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 968.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 968.85, "10th_percentile": 968.85, "90th_percentile": 968.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 968.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 968.85, "10th_percentile": 968.85, "90th_percentile": 968.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 111.42, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.42, "10th_percentile": 111.42, "90th_percentile": 111.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 111.42, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.42, "10th_percentile": 111.42, "90th_percentile": 111.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 111.42, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.42, "10th_percentile": 111.42, "90th_percentile": 111.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 284.2, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 284.2, "10th_percentile": 284.2, "90th_percentile": 284.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 284.2, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 284.2, "10th_percentile": 284.2, "90th_percentile": 284.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 663.34, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 663.34, "10th_percentile": 663.34, "90th_percentile": 663.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 663.34, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 663.34, "10th_percentile": 663.34, "90th_percentile": 663.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 230.91, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 230.91, "10th_percentile": 230.91, "90th_percentile": 230.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 565.16, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 565.16, "10th_percentile": 565.16, "90th_percentile": 565.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 484.43, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 484.43, "10th_percentile": 484.43, "90th_percentile": 484.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1291.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1291.8, "10th_percentile": 1291.8, "90th_percentile": 1291.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 926.87, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 926.87, "10th_percentile": 926.87, "90th_percentile": 926.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 968.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 968.85, "10th_percentile": 968.85, "90th_percentile": 968.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1241.74, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1241.74, "10th_percentile": 1241.74, "90th_percentile": 1241.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 807.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 807.38, "10th_percentile": 807.38, "90th_percentile": 807.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1404.83, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1404.83, "10th_percentile": 1404.83, "90th_percentile": 1404.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1236.9, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1236.9, "10th_percentile": 1236.9, "90th_percentile": 1236.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1472.65, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1472.65, "10th_percentile": 1472.65, "90th_percentile": 1472.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1017.29, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1017.29, "10th_percentile": 1017.29, "90th_percentile": 1017.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 807.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 807.38, "10th_percentile": 807.38, "90th_percentile": 807.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1291.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1291.8, "10th_percentile": 1291.8, "90th_percentile": 1291.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "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": 129.13, "maximum": 1871.5, "setting": "outpatient", "gross_charge": 1871.5, "discounted_cash": 1310.05, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,871.50 @ 11.5% = $215.22 due to $0.00 Claim Price", "median_amount": 215.22, "10th_percentile": 215.22, "90th_percentile": 215.22, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,871.50 @ 11.5% = $215.22 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,871.50 @ 11.5% = $215.22 due to $0.00 Claim Price", "median_amount": 215.22, "10th_percentile": 215.22, "90th_percentile": 215.22, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,871.50 @ 11.5% = $215.22 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 207.74, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 207.74, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 207.74, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 207.74, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 207.74, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 207.74, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1122.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1122.9, "10th_percentile": 1122.9, "90th_percentile": 1122.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1122.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1122.9, "10th_percentile": 1122.9, "90th_percentile": 1122.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1122.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1122.9, "10th_percentile": 1122.9, "90th_percentile": 1122.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 129.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 129.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 129.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "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": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,871.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,871.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,871.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,871.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,871.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,871.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1871.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1871.5, "10th_percentile": 1871.5, "90th_percentile": 1871.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 768.81, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.81, "10th_percentile": 768.81, "90th_percentile": 768.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 768.81, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.81, "10th_percentile": 768.81, "90th_percentile": 768.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 329.38, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.38, "10th_percentile": 329.38, "90th_percentile": 329.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 329.38, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.38, "10th_percentile": 329.38, "90th_percentile": 329.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 267.62, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 267.62, "10th_percentile": 267.62, "90th_percentile": 267.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 655.03, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 655.03, "10th_percentile": 655.03, "90th_percentile": 655.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 561.45, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 561.45, "10th_percentile": 561.45, "90th_percentile": 561.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 587.65, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 587.65, "10th_percentile": 587.65, "90th_percentile": 587.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1122.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1122.9, "10th_percentile": 1122.9, "90th_percentile": 1122.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 935.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 935.75, "10th_percentile": 935.75, "90th_percentile": 935.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1439.18, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1439.18, "10th_percentile": 1439.18, "90th_percentile": 1439.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1074.24, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1074.24, "10th_percentile": 1074.24, "90th_percentile": 1074.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1433.57, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1433.57, "10th_percentile": 1433.57, "90th_percentile": 1433.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 935.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 935.75, "10th_percentile": 935.75, "90th_percentile": 935.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1706.81, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1706.81, "10th_percentile": 1706.81, "90th_percentile": 1706.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1628.21, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1628.21, "10th_percentile": 1628.21, "90th_percentile": 1628.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1497.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1497.2, "10th_percentile": 1497.2, "90th_percentile": 1497.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1179.05, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1179.05, "10th_percentile": 1179.05, "90th_percentile": 1179.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1497.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1497.2, "10th_percentile": 1497.2, "90th_percentile": 1497.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "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": 3.22, "maximum": 22.5, "setting": "outpatient", "gross_charge": 22.5, "discounted_cash": 15.75, "payers_information": [ { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9.23, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.23, "10th_percentile": 9.23, "90th_percentile": 9.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 9.24, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.24, "10th_percentile": 9.24, "90th_percentile": 9.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 10.09, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.09, "10th_percentile": 10.09, "90th_percentile": 10.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 11.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.25, "10th_percentile": 11.25, "90th_percentile": 11.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 17.24, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 17.24, "10th_percentile": 17.24, "90th_percentile": 17.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 4.82, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.82, "10th_percentile": 4.82, "90th_percentile": 4.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 18.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 9.29, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.29, "10th_percentile": 9.29, "90th_percentile": 9.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 18.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 17.3, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 17.3, "10th_percentile": 17.3, "90th_percentile": 17.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 20.52, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 20.52, "10th_percentile": 20.52, "90th_percentile": 20.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 11.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 11.25, "10th_percentile": 11.25, "90th_percentile": 11.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 14.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% 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; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 22.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.5, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 19.58, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 19.58, "10th_percentile": 19.58, "90th_percentile": 19.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 12.92, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 12.92, "10th_percentile": 12.92, "90th_percentile": 12.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 14.45, "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": 14.45, "10th_percentile": 14.45, "90th_percentile": 14.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 11.3, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.3, "10th_percentile": 11.3, "90th_percentile": 11.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 15.05, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.05, "10th_percentile": 15.05, "90th_percentile": 15.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 22.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 13.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 13.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 12.96, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.96, "10th_percentile": 12.96, "90th_percentile": 12.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.22, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 3.22, "10th_percentile": 3.22, "90th_percentile": 3.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 11.88, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.88, "10th_percentile": 11.88, "90th_percentile": 11.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 7.88, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 7.88, "10th_percentile": 7.88, "90th_percentile": 7.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 7.07, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 7.07, "10th_percentile": 7.07, "90th_percentile": 7.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 6.75, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 22.5, "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 $22.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "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 $22.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 22.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 22.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 22.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 13.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9.23, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.23, "10th_percentile": 9.23, "90th_percentile": 9.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.5, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 10.09, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.09, "10th_percentile": 10.09, "90th_percentile": 10.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 9.24, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.24, "10th_percentile": 9.24, "90th_percentile": 9.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.57, "10th_percentile": 8.57, "90th_percentile": 8.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.57, "10th_percentile": 8.57, "90th_percentile": 8.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.57, "10th_percentile": 8.57, "90th_percentile": 8.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.57, "10th_percentile": 8.57, "90th_percentile": 8.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG/0.5 ML INH NEBU", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-97580", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00487-9901-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.04, "maximum": 21.25, "setting": "outpatient", "gross_charge": 21.25, "discounted_cash": 14.87, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 13.65, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 13.65, "10th_percentile": 13.65, "90th_percentile": 13.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH UHC CORE", "standard_charge_dollar": 10.67, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 14.22, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "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": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.72, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.72, "10th_percentile": 8.72, "90th_percentile": 8.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.09, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.09, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8.73, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.73, "10th_percentile": 8.73, "90th_percentile": 8.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 21.25, "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 $21.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "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 $21.25 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": "CDH BCBS PPO", "standard_charge_dollar": 9.53, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.53, "10th_percentile": 9.53, "90th_percentile": 9.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.25, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 11.22, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.22, "10th_percentile": 11.22, "90th_percentile": 11.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 6.67, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 6.67, "10th_percentile": 6.67, "90th_percentile": 6.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 12.24, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.24, "10th_percentile": 12.24, "90th_percentile": 12.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 6.38, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 7.44, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 7.44, "10th_percentile": 7.44, "90th_percentile": 7.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.04, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 3.04, "10th_percentile": 3.04, "90th_percentile": 3.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.72, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.72, "10th_percentile": 8.72, "90th_percentile": 8.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.09, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.09, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8.73, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.73, "10th_percentile": 8.73, "90th_percentile": 8.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 9.53, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.53, "10th_percentile": 9.53, "90th_percentile": 9.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 10.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 16.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% 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; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 4.55, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.55, "10th_percentile": 4.55, "90th_percentile": 4.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 17.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 17.0, "10th_percentile": 17.0, "90th_percentile": 17.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 8.78, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.78, "10th_percentile": 8.78, "90th_percentile": 8.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 17.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 17.0, "10th_percentile": 17.0, "90th_percentile": 17.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 16.34, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 16.34, "10th_percentile": 16.34, "90th_percentile": 16.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 19.38, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 19.38, "10th_percentile": 19.38, "90th_percentile": 19.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 10.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 10.63, "10th_percentile": 10.63, "90th_percentile": 10.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 13.39, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.25, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 21.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21.25, "10th_percentile": 21.25, "90th_percentile": 21.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 18.49, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 18.49, "10th_percentile": 18.49, "90th_percentile": 18.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 12.2, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 12.2, "10th_percentile": 12.2, "90th_percentile": 12.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" } ] } ] }, { "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": 83.3, "maximum": 582.5, "setting": "outpatient", "gross_charge": 582.5, "discounted_cash": 407.75, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 307.56, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.56, "10th_percentile": 307.56, "90th_percentile": 307.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 182.91, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 182.91, "10th_percentile": 182.91, "90th_percentile": 182.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 335.52, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 335.52, "10th_percentile": 335.52, "90th_percentile": 335.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 174.75, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 174.75, "10th_percentile": 174.75, "90th_percentile": 174.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 203.88, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 203.88, "10th_percentile": 203.88, "90th_percentile": 203.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 83.3, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 83.3, "10th_percentile": 83.3, "90th_percentile": 83.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 239.0, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.0, "10th_percentile": 239.0, "90th_percentile": 239.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 221.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.76, "10th_percentile": 221.76, "90th_percentile": 221.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 221.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.76, "10th_percentile": 221.76, "90th_percentile": 221.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 239.29, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.29, "10th_percentile": 239.29, "90th_percentile": 239.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 261.31, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.31, "10th_percentile": 261.31, "90th_percentile": 261.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 291.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.25, "10th_percentile": 291.25, "90th_percentile": 291.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 446.2, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 446.2, "10th_percentile": 446.2, "90th_percentile": 446.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 124.66, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.66, "10th_percentile": 124.66, "90th_percentile": 124.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 466.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 466.0, "10th_percentile": 466.0, "90th_percentile": 466.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 240.57, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 240.57, "10th_percentile": 240.57, "90th_percentile": 240.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 466.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 466.0, "10th_percentile": 466.0, "90th_percentile": 466.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 349.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 349.5, "10th_percentile": 349.5, "90th_percentile": 349.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 447.94, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 447.94, "10th_percentile": 447.94, "90th_percentile": 447.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 531.24, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 531.24, "10th_percentile": 531.24, "90th_percentile": 531.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 291.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 291.25, "10th_percentile": 291.25, "90th_percentile": 291.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 366.98, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 366.98, "10th_percentile": 366.98, "90th_percentile": 366.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 349.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 349.5, "10th_percentile": 349.5, "90th_percentile": 349.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 116.5, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 116.5, "10th_percentile": 116.5, "90th_percentile": 116.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 349.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 349.5, "10th_percentile": 349.5, "90th_percentile": 349.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 506.78, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 506.78, "10th_percentile": 506.78, "90th_percentile": 506.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 334.36, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 334.36, "10th_percentile": 334.36, "90th_percentile": 334.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 374.14, "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": 374.14, "10th_percentile": 374.14, "90th_percentile": 374.14, "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": "CDH UHC CORE", "standard_charge_dollar": 292.42, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 292.42, "10th_percentile": 292.42, "90th_percentile": 292.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 389.69, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 389.69, "10th_percentile": 389.69, "90th_percentile": 389.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 582.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 582.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 582.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 349.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 349.5, "10th_percentile": 349.5, "90th_percentile": 349.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 239.0, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.0, "10th_percentile": 239.0, "90th_percentile": 239.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 221.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.76, "10th_percentile": 221.76, "90th_percentile": 221.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 221.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.76, "10th_percentile": 221.76, "90th_percentile": 221.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 239.29, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.29, "10th_percentile": 239.29, "90th_percentile": 239.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 261.31, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.31, "10th_percentile": 261.31, "90th_percentile": 261.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 116.5, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 116.5, "10th_percentile": 116.5, "90th_percentile": 116.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 582.5, "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 $582.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "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 $582.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 582.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $582.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $582.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 582.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $582.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $582.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 582.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 582.5, "10th_percentile": 582.5, "90th_percentile": 582.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 11965.98, "maximum": 27956.6, "setting": "inpatient", "gross_charge": 50587.74, "discounted_cash": 35411.42, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services - OON; 100% Billed", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 50586.76, "10th_percentile": 50586.76, "90th_percentile": 50586.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 7233.91, "10th_percentile": 7233.91, "90th_percentile": 7233.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All Inpatient Services; 37% Billed", "median_amount": 18717.1, "10th_percentile": 18717.1, "90th_percentile": 18717.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All Inpatient Services; 32.6% Billed", "median_amount": 16491.28, "10th_percentile": 16491.28, "90th_percentile": 16491.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 30% Billed", "median_amount": 15176.03, "10th_percentile": 15176.03, "90th_percentile": 15176.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 30352.04, "10th_percentile": 30352.04, "90th_percentile": 30352.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 30352.04, "10th_percentile": 30352.04, "90th_percentile": 30352.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 30352.04, "10th_percentile": 30352.04, "90th_percentile": 30352.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; IP Services; 92% Billed", "median_amount": 46539.82, "10th_percentile": 46539.82, "90th_percentile": 46539.82, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; 92% Billed", "median_amount": 46539.82, "10th_percentile": 46539.82, "90th_percentile": 46539.82, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 25293.4, "10th_percentile": 25293.4, "90th_percentile": 25293.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 25293.4, "10th_percentile": 25293.4, "90th_percentile": 25293.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient Services; 63% Billed", "median_amount": 31869.66, "10th_percentile": 31869.66, "90th_percentile": 31869.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All Inpatient Services; 75.1% Billed", "median_amount": 37990.66, "10th_percentile": 37990.66, "90th_percentile": 37990.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 40469.42, "10th_percentile": 40469.42, "90th_percentile": 40469.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14670.16, "10th_percentile": 14670.16, "90th_percentile": 14670.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 29542.67, "10th_percentile": 29542.67, "90th_percentile": 29542.67, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44010.47, "10th_percentile": 44010.47, "90th_percentile": 44010.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 22353.51, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 22353.51, "10th_percentile": 22353.51, "90th_percentile": 22353.51, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 27956.6, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 20369.5, "10th_percentile": 20369.5, "90th_percentile": 20369.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 21087.26, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 21087.26, "10th_percentile": 21087.26, "90th_percentile": 21087.26, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22985.79, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 22985.79, "10th_percentile": 22985.79, "90th_percentile": 22985.79, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 17799.74, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 17799.74, "10th_percentile": 17799.74, "90th_percentile": 17799.74, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 17799.74, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 17799.74, "10th_percentile": 17799.74, "90th_percentile": 17799.74, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22985.79, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 22985.79, "10th_percentile": 22985.79, "90th_percentile": 22985.79, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 22353.51, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 22353.51, "10th_percentile": 22353.51, "90th_percentile": 22353.51, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 21087.26, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 21087.26, "10th_percentile": 21087.26, "90th_percentile": 21087.26, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 27956.6, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 20369.5, "10th_percentile": 20369.5, "90th_percentile": 20369.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,585.49; Total: $14,585.49", "median_amount": 14585.49, "10th_percentile": 14585.49, "90th_percentile": 14585.49, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,585.49; Total: $14,585.49" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,585.49; Total: $14,585.49", "median_amount": 14585.49, "10th_percentile": 14585.49, "90th_percentile": 14585.49, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,585.49; Total: $14,585.49" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; 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: $12,867.73; Total: $12,867.73 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12867.73, "10th_percentile": 12867.73, "90th_percentile": 12867.73, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; 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: $12,867.73; Total: $12,867.73 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $14,585.49; Percentage applied: 97.00%; Total: $14,147.93 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14147.93, "10th_percentile": 14147.93, "90th_percentile": 14147.93, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.850818495; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $14,585.49; Percentage applied: 97.00%; Total: $14,147.93 Paid at contractual rate, which is 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": "ALLOGRAFT TRIAD CC LORDOTIC 6X11X14MM", "code_information": [ { "code": "SUP-336922", "type": "CDM" }, { "code": "C1734", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 458.08, "maximum": 6638.9, "setting": "outpatient", "gross_charge": 6638.9, "discounted_cash": 4647.23, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,638.90 @ 11.5% = $763.47 due to $0.00 Claim Price", "median_amount": 763.47, "10th_percentile": 763.47, "90th_percentile": 763.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,638.90 @ 11.5% = $763.47 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,638.90 @ 11.5% = $763.47 due to $0.00 Claim Price", "median_amount": 763.47, "10th_percentile": 763.47, "90th_percentile": 763.47, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,638.90 @ 11.5% = $763.47 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2727.26, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2727.26, "10th_percentile": 2727.26, "90th_percentile": 2727.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2727.26, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2727.26, "10th_percentile": 2727.26, "90th_percentile": 2727.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 3319.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 3319.45, "10th_percentile": 3319.45, "90th_percentile": 3319.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1327.78, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1327.78, "10th_percentile": 1327.78, "90th_percentile": 1327.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1327.78, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1327.78, "10th_percentile": 1327.78, "90th_percentile": 1327.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 3332.73, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3332.73, "10th_percentile": 3332.73, "90th_percentile": 3332.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1420.72, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1420.72, "10th_percentile": 1420.72, "90th_percentile": 1420.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 3319.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3319.45, "10th_percentile": 3319.45, "90th_percentile": 3319.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 5311.12, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 5311.12, "10th_percentile": 5311.12, "90th_percentile": 5311.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5311.12, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5311.12, "10th_percentile": 5311.12, "90th_percentile": 5311.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 5085.4, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 5085.4, "10th_percentile": 5085.4, "90th_percentile": 5085.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3983.34, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3983.34, "10th_percentile": 3983.34, "90th_percentile": 3983.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 6054.68, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 6054.68, "10th_percentile": 6054.68, "90th_percentile": 6054.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3810.73, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3810.73, "10th_percentile": 3810.73, "90th_percentile": 3810.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5775.84, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5775.84, "10th_percentile": 5775.84, "90th_percentile": 5775.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 5105.31, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 5105.31, "10th_percentile": 5105.31, "90th_percentile": 5105.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 4264.17, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4264.17, "10th_percentile": 4264.17, "90th_percentile": 4264.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 4441.42, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4441.42, "10th_percentile": 4441.42, "90th_percentile": 4441.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 4182.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 4182.51, "10th_percentile": 4182.51, "90th_percentile": 4182.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2741.87, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2741.87, "10th_percentile": 2741.87, "90th_percentile": 2741.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 949.36, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 949.36, "10th_percentile": 949.36, "90th_percentile": 949.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3824.01, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3824.01, "10th_percentile": 3824.01, "90th_percentile": 3824.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2323.62, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2323.62, "10th_percentile": 2323.62, "90th_percentile": 2323.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3505.34, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3505.34, "10th_percentile": 3505.34, "90th_percentile": 3505.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2084.61, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2084.61, "10th_percentile": 2084.61, "90th_percentile": 2084.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1991.67, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1991.67, "10th_percentile": 1991.67, "90th_percentile": 1991.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1168.45, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1168.45, "10th_percentile": 1168.45, "90th_percentile": 1168.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1168.45, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1168.45, "10th_percentile": 1168.45, "90th_percentile": 1168.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 458.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.08, "10th_percentile": 458.08, "90th_percentile": 458.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 458.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.08, "10th_percentile": 458.08, "90th_percentile": 458.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 458.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.08, "10th_percentile": 458.08, "90th_percentile": 458.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6638.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6638.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 6638.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 6638.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,638.90 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,638.90 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6638.9, "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 $6,638.90 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "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 $6,638.90 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 6638.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,638.90 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,638.90 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 6638.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 6638.9, "10th_percentile": 6638.9, "90th_percentile": 6638.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3983.34, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3983.34, "10th_percentile": 3983.34, "90th_percentile": 3983.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3983.34, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3983.34, "10th_percentile": 3983.34, "90th_percentile": 3983.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3983.34, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3983.34, "10th_percentile": 3983.34, "90th_percentile": 3983.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 736.92, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 736.92, "10th_percentile": 736.92, "90th_percentile": 736.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 736.92, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 736.92, "10th_percentile": 736.92, "90th_percentile": 736.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 736.92, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 736.92, "10th_percentile": 736.92, "90th_percentile": 736.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 736.92, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 736.92, "10th_percentile": 736.92, "90th_percentile": 736.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 736.92, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 736.92, "10th_percentile": 736.92, "90th_percentile": 736.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 736.92, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 736.92, "10th_percentile": 736.92, "90th_percentile": 736.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "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": "00591-5543-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.4, "maximum": 16.75, "setting": "outpatient", "gross_charge": 16.75, "discounted_cash": 11.72, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 10.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 3.35, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 9.65, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.65, "10th_percentile": 9.65, "90th_percentile": 9.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 5.26, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 5.26, "10th_percentile": 5.26, "90th_percentile": 5.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 8.84, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.84, "10th_percentile": 8.84, "90th_percentile": 8.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 5.86, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 5.86, "10th_percentile": 5.86, "90th_percentile": 5.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.4, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% 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; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 5.03, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 5.03, "10th_percentile": 5.03, "90th_percentile": 5.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6.87, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.87, "10th_percentile": 6.87, "90th_percentile": 6.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6.87, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.87, "10th_percentile": 6.87, "90th_percentile": 6.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 6.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.88, "10th_percentile": 6.88, "90th_percentile": 6.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 6.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.88, "10th_percentile": 6.88, "90th_percentile": 6.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 7.51, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.51, "10th_percentile": 7.51, "90th_percentile": 7.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 7.51, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.51, "10th_percentile": 7.51, "90th_percentile": 7.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 16.75, "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 $16.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "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 $16.75 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $16.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $16.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $16.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $16.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 10.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 10.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 16.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 16.75, "10th_percentile": 16.75, "90th_percentile": 16.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 3.35, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 8.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 11.21, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.21, "10th_percentile": 11.21, "90th_percentile": 11.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 10.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 12.83, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 12.83, "10th_percentile": 12.83, "90th_percentile": 12.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 13.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 13.4, "10th_percentile": 13.4, "90th_percentile": 13.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 8.41, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.41, "10th_percentile": 8.41, "90th_percentile": 8.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 9.61, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 9.61, "10th_percentile": 9.61, "90th_percentile": 9.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 3.58, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.58, "10th_percentile": 3.58, "90th_percentile": 3.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 14.57, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 14.57, "10th_percentile": 14.57, "90th_percentile": 14.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 10.76, "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": 10.76, "10th_percentile": 10.76, "90th_percentile": 10.76, "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": "CDH CIGNA BROAD", "standard_charge_dollar": 6.92, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 10.55, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% 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 Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 13.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 13.4, "10th_percentile": 13.4, "90th_percentile": 13.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 12.88, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 12.88, "10th_percentile": 12.88, "90th_percentile": 12.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 15.28, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 15.28, "10th_percentile": 15.28, "90th_percentile": 15.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" } ] } ] }, { "description": "ALLOPURINOL 300 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-311", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00591-5544-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.41, "maximum": 20.5, "setting": "outpatient", "gross_charge": 20.5, "discounted_cash": 14.35, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3.61, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.61, "10th_percentile": 3.61, "90th_percentile": 3.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3.61, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.61, "10th_percentile": 3.61, "90th_percentile": 3.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.93, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 2.93, "10th_percentile": 2.93, "90th_percentile": 2.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 7.18, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 7.18, "10th_percentile": 7.18, "90th_percentile": 7.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 6.15, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 6.15, "10th_percentile": 6.15, "90th_percentile": 6.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 11.81, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.81, "10th_percentile": 11.81, "90th_percentile": 11.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 6.44, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 6.44, "10th_percentile": 6.44, "90th_percentile": 6.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 10.82, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8.42, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.42, "10th_percentile": 8.42, "90th_percentile": 8.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8.42, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.42, "10th_percentile": 8.42, "90th_percentile": 8.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.5, "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 $20.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.3, "10th_percentile": 12.3, "90th_percentile": 12.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.28, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.28, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.28, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.28, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.28, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.28, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.50 @ 11.5% = $2.36 due to $0.00 Claim Price", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.50 @ 11.5% = $2.36 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 13.71, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.71, "10th_percentile": 13.71, "90th_percentile": 13.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 10.29, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.29, "10th_percentile": 10.29, "90th_percentile": 10.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 16.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 16.4, "10th_percentile": 16.4, "90th_percentile": 16.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 16.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 16.4, "10th_percentile": 16.4, "90th_percentile": 16.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 15.7, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 15.7, "10th_percentile": 15.7, "90th_percentile": 15.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 13.17, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 13.17, "10th_percentile": 13.17, "90th_percentile": 13.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 15.76, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 15.76, "10th_percentile": 15.76, "90th_percentile": 15.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 10.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 11.77, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 11.77, "10th_percentile": 11.77, "90th_percentile": 11.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 12.92, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 12.92, "10th_percentile": 12.92, "90th_percentile": 12.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 18.7, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 18.7, "10th_percentile": 18.7, "90th_percentile": 18.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 17.84, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 10.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% 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 OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 12.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 12.3, "10th_percentile": 12.3, "90th_percentile": 12.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.1, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.1, "10th_percentile": 4.1, "90th_percentile": 4.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.1, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.1, "10th_percentile": 4.1, "90th_percentile": 4.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 20.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 20.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 20.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 20.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 20.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1.41, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1.41, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1.41, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.3, "10th_percentile": 12.3, "90th_percentile": 12.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.3, "10th_percentile": 12.3, "90th_percentile": 12.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.50 @ 11.5% = $2.36 due to $0.00 Claim Price", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $20.50 @ 11.5% = $2.36 due to $0.00 Claim Price" } ] } ] }, { "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": 1.72, "maximum": 12.0, "setting": "outpatient", "gross_charge": 12.0, "discounted_cash": 8.4, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.57, "10th_percentile": 4.57, "90th_percentile": 4.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.57, "10th_percentile": 4.57, "90th_percentile": 4.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.57, "10th_percentile": 4.57, "90th_percentile": 4.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.57, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.57, "10th_percentile": 4.57, "90th_percentile": 4.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 7.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 7.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 7.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 6.89, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 6.89, "10th_percentile": 6.89, "90th_percentile": 6.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 6.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 10.94, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 10.94, "10th_percentile": 10.94, "90th_percentile": 10.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 6.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 10.44, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 10.44, "10th_percentile": 10.44, "90th_percentile": 10.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 9.23, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 9.23, "10th_percentile": 9.23, "90th_percentile": 9.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.57, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.57, "10th_percentile": 2.57, "90th_percentile": 2.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 9.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 9.6, "10th_percentile": 9.6, "90th_percentile": 9.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 7.56, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 7.56, "10th_percentile": 7.56, "90th_percentile": 7.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 9.19, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 7.71, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7.71, "10th_percentile": 7.71, "90th_percentile": 7.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 7.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 4.96, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.96, "10th_percentile": 4.96, "90th_percentile": 4.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 8.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.03, "10th_percentile": 8.03, "90th_percentile": 8.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 9.6, "10th_percentile": 9.6, "90th_percentile": 9.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 6.02, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.02, "10th_percentile": 6.02, "90th_percentile": 6.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 2.4, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 2.4, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 6.91, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.91, "10th_percentile": 6.91, "90th_percentile": 6.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 3.77, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 3.77, "10th_percentile": 3.77, "90th_percentile": 3.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 6.34, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.34, "10th_percentile": 6.34, "90th_percentile": 6.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 4.2, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% 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; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.72, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1.72, "10th_percentile": 1.72, "90th_percentile": 1.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 3.6, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 3.6, "10th_percentile": 3.6, "90th_percentile": 3.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.92, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.92, "10th_percentile": 4.92, "90th_percentile": 4.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.92, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.92, "10th_percentile": 4.92, "90th_percentile": 4.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 4.93, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.93, "10th_percentile": 4.93, "90th_percentile": 4.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 4.93, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.93, "10th_percentile": 4.93, "90th_percentile": 4.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5.38, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5.38, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" } ] } ] }, { "description": "ALUM-MAG HYDROXIDE-SIMETH 400-400-40 MG/5 ML ORAL SUSP", "drug_information": { "unit": 15.0, "type": "ML" }, "code_information": [ { "code": "RX-9015", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00000-1002-50", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.14, "maximum": 1.0, "setting": "outpatient", "gross_charge": 1.0, "discounted_cash": 0.7, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 0.53, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 0.31, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 0.58, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 0.3, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 0.3, "10th_percentile": 0.3, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 0.35, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 0.35, "10th_percentile": 0.35, "90th_percentile": 0.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.14, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 0.14, "10th_percentile": 0.14, "90th_percentile": 0.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.5, "10th_percentile": 0.5, "90th_percentile": 0.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 0.67, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.41, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 0.41, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 0.45, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.5, "10th_percentile": 0.5, "90th_percentile": 0.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 0.77, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.21, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.21, "10th_percentile": 0.21, "90th_percentile": 0.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 0.8, "10th_percentile": 0.8, "90th_percentile": 0.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 0.41, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 0.8, "10th_percentile": 0.8, "90th_percentile": 0.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 0.6, "10th_percentile": 0.6, "90th_percentile": 0.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 0.77, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 0.91, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 0.5, "10th_percentile": 0.5, "90th_percentile": 0.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 0.63, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 0.63, "10th_percentile": 0.63, "90th_percentile": 0.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 0.6, "10th_percentile": 0.6, "90th_percentile": 0.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 0.2, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 0.2, "10th_percentile": 0.2, "90th_percentile": 0.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 0.6, "10th_percentile": 0.6, "90th_percentile": 0.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 0.87, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 0.87, "10th_percentile": 0.87, "90th_percentile": 0.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 0.57, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 0.57, "10th_percentile": 0.57, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH 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": 0.64, "10th_percentile": 0.64, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "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": "CDH ADVOCATE IPA", "standard_charge_dollar": 0.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 0.6, "10th_percentile": 0.6, "90th_percentile": 0.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.41, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 0.41, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH 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": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1.00 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": "CDH BCBS PPO", "standard_charge_dollar": 0.45, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 0.2, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 0.2, "10th_percentile": 0.2, "90th_percentile": 0.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 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": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 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": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 171.92, "maximum": 1202.25, "setting": "outpatient", "gross_charge": 1202.25, "discounted_cash": 841.57, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 924.53, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 924.53, "10th_percentile": 924.53, "90th_percentile": 924.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1096.45, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1096.45, "10th_percentile": 1096.45, "90th_percentile": 1096.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 601.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 601.13, "10th_percentile": 601.13, "90th_percentile": 601.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 757.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 757.42, "10th_percentile": 757.42, "90th_percentile": 757.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1202.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 240.45, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 240.45, "10th_percentile": 240.45, "90th_percentile": 240.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 721.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 721.35, "10th_percentile": 721.35, "90th_percentile": 721.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1045.96, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1045.96, "10th_percentile": 1045.96, "90th_percentile": 1045.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 690.09, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 690.09, "10th_percentile": 690.09, "90th_percentile": 690.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 772.21, "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": 772.21, "10th_percentile": 772.21, "90th_percentile": 772.21, "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": "CDH UHC CORE", "standard_charge_dollar": 603.53, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 603.53, "10th_percentile": 603.53, "90th_percentile": 603.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 804.31, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 804.31, "10th_percentile": 804.31, "90th_percentile": 804.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1202.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1202.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 634.79, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 634.79, "10th_percentile": 634.79, "90th_percentile": 634.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 377.51, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 377.51, "10th_percentile": 377.51, "90th_percentile": 377.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 692.5, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 692.5, "10th_percentile": 692.5, "90th_percentile": 692.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 360.68, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 360.68, "10th_percentile": 360.68, "90th_percentile": 360.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 420.79, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 420.79, "10th_percentile": 420.79, "90th_percentile": 420.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 171.92, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 171.92, "10th_percentile": 171.92, "90th_percentile": 171.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 493.28, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 493.28, "10th_percentile": 493.28, "90th_percentile": 493.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 457.7, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.7, "10th_percentile": 457.7, "90th_percentile": 457.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 457.7, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.7, "10th_percentile": 457.7, "90th_percentile": 457.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 493.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 493.88, "10th_percentile": 493.88, "90th_percentile": 493.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 539.33, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 539.33, "10th_percentile": 539.33, "90th_percentile": 539.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 601.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.13, "10th_percentile": 601.13, "90th_percentile": 601.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 920.92, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 920.92, "10th_percentile": 920.92, "90th_percentile": 920.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 257.28, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.28, "10th_percentile": 257.28, "90th_percentile": 257.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 961.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 961.8, "10th_percentile": 961.8, "90th_percentile": 961.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 496.53, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 496.53, "10th_percentile": 496.53, "90th_percentile": 496.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 961.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 961.8, "10th_percentile": 961.8, "90th_percentile": 961.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 721.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 721.35, "10th_percentile": 721.35, "90th_percentile": 721.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 721.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 721.35, "10th_percentile": 721.35, "90th_percentile": 721.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 539.33, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 539.33, "10th_percentile": 539.33, "90th_percentile": 539.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 721.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 721.35, "10th_percentile": 721.35, "90th_percentile": 721.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 240.45, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 240.45, "10th_percentile": 240.45, "90th_percentile": 240.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 493.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 493.88, "10th_percentile": 493.88, "90th_percentile": 493.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 493.28, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 493.28, "10th_percentile": 493.28, "90th_percentile": 493.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1202.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,202.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,202.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1202.25, "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 $1,202.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "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 $1,202.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1202.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,202.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,202.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1202.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1202.25, "10th_percentile": 1202.25, "90th_percentile": 1202.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 457.7, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.7, "10th_percentile": 457.7, "90th_percentile": 457.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 457.7, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 457.7, "10th_percentile": 457.7, "90th_percentile": 457.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "00409-5922-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 18.41, "maximum": 266.75, "setting": "outpatient", "gross_charge": 266.75, "discounted_cash": 186.72, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.26, "10th_percentile": 10.26, "90th_percentile": 10.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 10.26, "10th_percentile": 10.26, "90th_percentile": 10.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $266.75 @ 11.5% = $30.68 due to $0.00 Claim Price", "median_amount": 30.68, "10th_percentile": 30.68, "90th_percentile": 30.68, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $266.75 @ 11.5% = $30.68 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $266.75 @ 11.5% = $30.68 due to $0.00 Claim Price", "median_amount": 30.68, "10th_percentile": 30.68, "90th_percentile": 30.68, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $266.75 @ 11.5% = $30.68 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 29.61, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 29.61, "10th_percentile": 29.61, "90th_percentile": 29.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 29.61, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 29.61, "10th_percentile": 29.61, "90th_percentile": 29.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 29.61, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 29.61, "10th_percentile": 29.61, "90th_percentile": 29.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 29.61, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 29.61, "10th_percentile": 29.61, "90th_percentile": 29.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 29.61, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 29.61, "10th_percentile": 29.61, "90th_percentile": 29.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 29.61, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 29.61, "10th_percentile": 29.61, "90th_percentile": 29.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 266.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 266.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 266.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 266.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $266.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $266.75 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 266.75, "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 $266.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "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 $266.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 266.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $266.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $266.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 266.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 266.75, "10th_percentile": 266.75, "90th_percentile": 266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 160.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 160.05, "10th_percentile": 160.05, "90th_percentile": 160.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 160.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 160.05, "10th_percentile": 160.05, "90th_percentile": 160.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 160.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 160.05, "10th_percentile": 160.05, "90th_percentile": 160.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 18.41, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.41, "10th_percentile": 18.41, "90th_percentile": 18.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 18.41, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.41, "10th_percentile": 18.41, "90th_percentile": 18.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 18.41, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.41, "10th_percentile": 18.41, "90th_percentile": 18.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 46.95, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.95, "10th_percentile": 46.95, "90th_percentile": 46.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 46.95, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.95, "10th_percentile": 46.95, "90th_percentile": 46.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 109.58, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.58, "10th_percentile": 109.58, "90th_percentile": 109.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 109.58, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.58, "10th_percentile": 109.58, "90th_percentile": 109.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 38.15, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 38.15, "10th_percentile": 38.15, "90th_percentile": 38.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 93.36, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 93.36, "10th_percentile": 93.36, "90th_percentile": 93.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 83.76, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 83.76, "10th_percentile": 83.76, "90th_percentile": 83.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 80.03, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 80.03, "10th_percentile": 80.03, "90th_percentile": 80.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 213.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 213.4, "10th_percentile": 213.4, "90th_percentile": 213.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 153.11, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 153.11, "10th_percentile": 153.11, "90th_percentile": 153.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 160.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 160.05, "10th_percentile": 160.05, "90th_percentile": 160.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 205.13, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 205.13, "10th_percentile": 205.13, "90th_percentile": 205.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 133.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 133.38, "10th_percentile": 133.38, "90th_percentile": 133.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 232.07, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 232.07, "10th_percentile": 232.07, "90th_percentile": 232.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 204.33, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 204.33, "10th_percentile": 204.33, "90th_percentile": 204.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 243.28, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 243.28, "10th_percentile": 243.28, "90th_percentile": 243.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 168.05, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 168.05, "10th_percentile": 168.05, "90th_percentile": 168.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 133.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 133.38, "10th_percentile": 133.38, "90th_percentile": 133.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 213.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 213.4, "10th_percentile": 213.4, "90th_percentile": 213.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "description": "AMIODARONE 50 MG/ML IV SOLN", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-9065", "type": "CDM" }, { "code": "J0282", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0616-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.71, "maximum": 68.25, "setting": "outpatient", "gross_charge": 68.25, "discounted_cash": 47.77, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.25 @ 11.5% = $7.85 due to $0.00 Claim Price", "median_amount": 7.85, "10th_percentile": 7.85, "90th_percentile": 7.85, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.25 @ 11.5% = $7.85 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.25 @ 11.5% = $7.85 due to $0.00 Claim Price", "median_amount": 7.85, "10th_percentile": 7.85, "90th_percentile": 7.85, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $68.25 @ 11.5% = $7.85 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.58, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.58, "10th_percentile": 7.58, "90th_percentile": 7.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.58, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.58, "10th_percentile": 7.58, "90th_percentile": 7.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.58, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.58, "10th_percentile": 7.58, "90th_percentile": 7.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.58, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.58, "10th_percentile": 7.58, "90th_percentile": 7.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.58, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.58, "10th_percentile": 7.58, "90th_percentile": 7.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.58, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.58, "10th_percentile": 7.58, "90th_percentile": 7.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 40.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 40.95, "10th_percentile": 40.95, "90th_percentile": 40.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 40.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 40.95, "10th_percentile": 40.95, "90th_percentile": 40.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 40.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 40.95, "10th_percentile": 40.95, "90th_percentile": 40.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 4.71, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.71, "10th_percentile": 4.71, "90th_percentile": 4.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 4.71, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.71, "10th_percentile": 4.71, "90th_percentile": 4.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 4.71, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.71, "10th_percentile": 4.71, "90th_percentile": 4.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 68.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 68.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 68.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $68.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $68.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 68.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $68.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $68.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 68.25, "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 $68.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $68.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 68.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 28.04, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.04, "10th_percentile": 28.04, "90th_percentile": 28.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 28.04, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.04, "10th_percentile": 28.04, "90th_percentile": 28.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 12.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.01, "10th_percentile": 12.01, "90th_percentile": 12.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 12.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.01, "10th_percentile": 12.01, "90th_percentile": 12.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 9.76, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 9.76, "10th_percentile": 9.76, "90th_percentile": 9.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 23.89, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 23.89, "10th_percentile": 23.89, "90th_percentile": 23.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 20.48, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 20.48, "10th_percentile": 20.48, "90th_percentile": 20.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 21.43, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 21.43, "10th_percentile": 21.43, "90th_percentile": 21.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 40.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 40.95, "10th_percentile": 40.95, "90th_percentile": 40.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 34.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.13, "10th_percentile": 34.13, "90th_percentile": 34.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 52.48, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 52.48, "10th_percentile": 52.48, "90th_percentile": 52.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 39.18, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 39.18, "10th_percentile": 39.18, "90th_percentile": 39.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 52.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 52.28, "10th_percentile": 52.28, "90th_percentile": 52.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 34.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 34.13, "10th_percentile": 34.13, "90th_percentile": 34.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 62.24, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 62.24, "10th_percentile": 62.24, "90th_percentile": 62.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 59.38, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 59.38, "10th_percentile": 59.38, "90th_percentile": 59.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 54.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 54.6, "10th_percentile": 54.6, "90th_percentile": 54.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 43.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 43.0, "10th_percentile": 43.0, "90th_percentile": 43.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 54.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 54.6, "10th_percentile": 54.6, "90th_percentile": 54.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 13.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 13.65, "10th_percentile": 13.65, "90th_percentile": 13.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 13.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 13.65, "10th_percentile": 13.65, "90th_percentile": 13.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 68.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN", "drug_information": { "unit": 100.0, "type": "ML" }, "code_information": [ { "code": "RX-191197", "type": "CDM" }, { "code": "J0283", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "43066-0150-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 38.66, "maximum": 560.25, "setting": "outpatient", "gross_charge": 560.25, "discounted_cash": 392.17, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $560.25 @ 11.5% = $64.43 due to $0.00 Claim Price", "median_amount": 64.43, "10th_percentile": 64.43, "90th_percentile": 64.43, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $560.25 @ 11.5% = $64.43 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $560.25 @ 11.5% = $64.43 due to $0.00 Claim Price", "median_amount": 64.43, "10th_percentile": 64.43, "90th_percentile": 64.43, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $560.25 @ 11.5% = $64.43 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 62.19, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 62.19, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 62.19, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 62.19, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 62.19, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 62.19, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $560.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $560.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 560.25, "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 $560.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "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 $560.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $560.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $560.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 560.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 560.25, "10th_percentile": 560.25, "90th_percentile": 560.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 336.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 336.15, "10th_percentile": 336.15, "90th_percentile": 336.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 336.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 336.15, "10th_percentile": 336.15, "90th_percentile": 336.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 336.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 336.15, "10th_percentile": 336.15, "90th_percentile": 336.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 38.66, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.66, "10th_percentile": 38.66, "90th_percentile": 38.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 38.66, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.66, "10th_percentile": 38.66, "90th_percentile": 38.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 38.66, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.66, "10th_percentile": 38.66, "90th_percentile": 38.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 98.6, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.6, "10th_percentile": 98.6, "90th_percentile": 98.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 98.6, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.6, "10th_percentile": 98.6, "90th_percentile": 98.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 230.15, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.15, "10th_percentile": 230.15, "90th_percentile": 230.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 230.15, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.15, "10th_percentile": 230.15, "90th_percentile": 230.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 80.12, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 80.12, "10th_percentile": 80.12, "90th_percentile": 80.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 196.09, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 196.09, "10th_percentile": 196.09, "90th_percentile": 196.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 175.92, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 175.92, "10th_percentile": 175.92, "90th_percentile": 175.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 168.08, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 168.08, "10th_percentile": 168.08, "90th_percentile": 168.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 448.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 448.2, "10th_percentile": 448.2, "90th_percentile": 448.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 321.58, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 321.58, "10th_percentile": 321.58, "90th_percentile": 321.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 336.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 336.15, "10th_percentile": 336.15, "90th_percentile": 336.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 430.83, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 430.83, "10th_percentile": 430.83, "90th_percentile": 430.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 280.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 280.13, "10th_percentile": 280.13, "90th_percentile": 280.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 487.42, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 487.42, "10th_percentile": 487.42, "90th_percentile": 487.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 429.15, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 429.15, "10th_percentile": 429.15, "90th_percentile": 429.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 510.95, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 510.95, "10th_percentile": 510.95, "90th_percentile": 510.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 352.96, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 352.96, "10th_percentile": 352.96, "90th_percentile": 352.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 280.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 280.13, "10th_percentile": 280.13, "90th_percentile": 280.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 448.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 448.2, "10th_percentile": 448.2, "90th_percentile": 448.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "description": "AMITRIPTYLINE 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-432", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "29300-0419-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.64, "maximum": 4.5, "setting": "outpatient", "gross_charge": 4.5, "discounted_cash": 3.15, "payers_information": [ { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.71, "10th_percentile": 1.71, "90th_percentile": 1.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.71, "10th_percentile": 1.71, "90th_percentile": 1.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.71, "10th_percentile": 1.71, "90th_percentile": 1.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.71, "10th_percentile": 1.71, "90th_percentile": 1.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 4.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 4.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4.5, "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 $4.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1.85, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1.85, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.85, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.85, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 0.9, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 0.9, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2.38, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1.41, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.64, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 0.64, "10th_percentile": 0.64, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1.58, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1.35, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2.59, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.59, "10th_percentile": 2.59, "90th_percentile": 2.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 3.6, "10th_percentile": 3.6, "90th_percentile": 3.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3.6, "10th_percentile": 3.6, "90th_percentile": 3.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2.02, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.02, "10th_percentile": 2.02, "90th_percentile": 2.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2.02, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.02, "10th_percentile": 2.02, "90th_percentile": 2.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 4.1, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 4.1, "10th_percentile": 4.1, "90th_percentile": 4.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 3.45, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.96, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1.86, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 3.46, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 3.46, "10th_percentile": 3.46, "90th_percentile": 3.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2.84, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2.84, "10th_percentile": 2.84, "90th_percentile": 2.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2.89, "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": 2.89, "10th_percentile": 2.89, "90th_percentile": 2.89, "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": "CDH UHC CORE", "standard_charge_dollar": 2.26, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.26, "10th_percentile": 2.26, "90th_percentile": 2.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3.92, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3.92, "10th_percentile": 3.92, "90th_percentile": 3.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2.58, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2.58, "10th_percentile": 2.58, "90th_percentile": 2.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 3.01, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.01, "10th_percentile": 3.01, "90th_percentile": 3.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "AMITRIPTYLINE 20 MG/ML ORAL SUSP (PEDS COMPOUND)", "drug_information": { "unit": 120.0, "type": "ML" }, "code_information": [ { "code": "RX-196105", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00000-1002-76", "type": "NDC" } ], "standard_charges": [ { "minimum": 612.54, "maximum": 4283.5, "setting": "outpatient", "gross_charge": 4283.5, "discounted_cash": 2998.45, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4283.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2261.69, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2261.69, "10th_percentile": 2261.69, "90th_percentile": 2261.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1345.02, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1345.02, "10th_percentile": 1345.02, "90th_percentile": 1345.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2467.3, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2467.3, "10th_percentile": 2467.3, "90th_percentile": 2467.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1285.05, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1285.05, "10th_percentile": 1285.05, "90th_percentile": 1285.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1499.23, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1499.23, "10th_percentile": 1499.23, "90th_percentile": 1499.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 612.54, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 612.54, "10th_percentile": 612.54, "90th_percentile": 612.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4283.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 2150.32, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2150.32, "10th_percentile": 2150.32, "90th_percentile": 2150.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2865.66, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2865.66, "10th_percentile": 2865.66, "90th_percentile": 2865.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3426.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3426.8, "10th_percentile": 3426.8, "90th_percentile": 3426.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 916.67, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 916.67, "10th_percentile": 916.67, "90th_percentile": 916.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1769.09, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1769.09, "10th_percentile": 1769.09, "90th_percentile": 1769.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 2141.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 2141.75, "10th_percentile": 2141.75, "90th_percentile": 2141.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3906.55, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3906.55, "10th_percentile": 3906.55, "90th_percentile": 3906.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1757.52, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1757.52, "10th_percentile": 1757.52, "90th_percentile": 1757.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1759.66, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1759.66, "10th_percentile": 1759.66, "90th_percentile": 1759.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1921.58, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1921.58, "10th_percentile": 1921.58, "90th_percentile": 1921.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 2751.29, "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": 2751.29, "10th_percentile": 2751.29, "90th_percentile": 2751.29, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3726.65, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3726.65, "10th_percentile": 3726.65, "90th_percentile": 3726.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2458.73, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2458.73, "10th_percentile": 2458.73, "90th_percentile": 2458.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 2141.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2141.75, "10th_percentile": 2141.75, "90th_percentile": 2141.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2570.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2570.1, "10th_percentile": 2570.1, "90th_percentile": 2570.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 3281.16, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 3281.16, "10th_percentile": 3281.16, "90th_percentile": 3281.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 3294.01, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 3294.01, "10th_percentile": 3294.01, "90th_percentile": 3294.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 3426.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 3426.8, "10th_percentile": 3426.8, "90th_percentile": 3426.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2570.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2570.1, "10th_percentile": 2570.1, "90th_percentile": 2570.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2698.61, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2698.61, "10th_percentile": 2698.61, "90th_percentile": 2698.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 4283.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2570.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2570.1, "10th_percentile": 2570.1, "90th_percentile": 2570.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 856.7, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 856.7, "10th_percentile": 856.7, "90th_percentile": 856.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1630.73, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1630.73, "10th_percentile": 1630.73, "90th_percentile": 1630.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1630.73, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1630.73, "10th_percentile": 1630.73, "90th_percentile": 1630.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1630.73, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1630.73, "10th_percentile": 1630.73, "90th_percentile": 1630.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1630.73, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1630.73, "10th_percentile": 1630.73, "90th_percentile": 1630.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 4283.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,283.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,283.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 4283.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,283.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,283.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4283.5, "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 $4,283.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "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 $4,283.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 4283.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 4283.5, "10th_percentile": 4283.5, "90th_percentile": 4283.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1759.66, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1759.66, "10th_percentile": 1759.66, "90th_percentile": 1759.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 856.7, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 856.7, "10th_percentile": 856.7, "90th_percentile": 856.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1921.58, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1921.58, "10th_percentile": 1921.58, "90th_percentile": 1921.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2570.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2570.1, "10th_percentile": 2570.1, "90th_percentile": 2570.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1757.52, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1757.52, "10th_percentile": 1757.52, "90th_percentile": 1757.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMMONIUM LACTATE 12 % TOP LOTN", "drug_information": { "unit": 225.0, "type": "GR" }, "code_information": [ { "code": "RX-10380", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "45802-0525-55", "type": "NDC" } ], "standard_charges": [ { "minimum": 60.99, "maximum": 426.5, "setting": "outpatient", "gross_charge": 426.5, "discounted_cash": 298.55, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 162.37, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.37, "10th_percentile": 162.37, "90th_percentile": 162.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 162.37, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.37, "10th_percentile": 162.37, "90th_percentile": 162.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 162.37, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.37, "10th_percentile": 162.37, "90th_percentile": 162.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 162.37, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.37, "10th_percentile": 162.37, "90th_percentile": 162.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 426.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 426.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 426.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 426.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $426.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $426.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 426.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $426.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $426.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 426.5, "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 $426.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "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 $426.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 426.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 255.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 255.9, "10th_percentile": 255.9, "90th_percentile": 255.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 255.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 255.9, "10th_percentile": 255.9, "90th_percentile": 255.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 255.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 255.9, "10th_percentile": 255.9, "90th_percentile": 255.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 175.21, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.21, "10th_percentile": 175.21, "90th_percentile": 175.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 175.21, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.21, "10th_percentile": 175.21, "90th_percentile": 175.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 85.3, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 85.3, "10th_percentile": 85.3, "90th_percentile": 85.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 85.3, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 85.3, "10th_percentile": 85.3, "90th_percentile": 85.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.99, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.99, "10th_percentile": 174.99, "90th_percentile": 174.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.99, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.99, "10th_percentile": 174.99, "90th_percentile": 174.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 133.92, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 133.92, "10th_percentile": 133.92, "90th_percentile": 133.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 225.19, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.19, "10th_percentile": 225.19, "90th_percentile": 225.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 245.66, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.66, "10th_percentile": 245.66, "90th_percentile": 245.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 60.99, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 60.99, "10th_percentile": 60.99, "90th_percentile": 60.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 127.95, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 127.95, "10th_percentile": 127.95, "90th_percentile": 127.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 149.28, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 149.28, "10th_percentile": 149.28, "90th_percentile": 149.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 191.33, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.33, "10th_percentile": 191.33, "90th_percentile": 191.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 191.33, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.33, "10th_percentile": 191.33, "90th_percentile": 191.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 176.14, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.14, "10th_percentile": 176.14, "90th_percentile": 176.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 285.33, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 285.33, "10th_percentile": 285.33, "90th_percentile": 285.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 244.81, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 244.81, "10th_percentile": 244.81, "90th_percentile": 244.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 268.7, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 268.7, "10th_percentile": 268.7, "90th_percentile": 268.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 341.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 341.2, "10th_percentile": 341.2, "90th_percentile": 341.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 326.7, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 326.7, "10th_percentile": 326.7, "90th_percentile": 326.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 213.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.25, "10th_percentile": 213.25, "90th_percentile": 213.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 91.27, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 214.1, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.1, "10th_percentile": 214.1, "90th_percentile": 214.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 341.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 341.2, "10th_percentile": 341.2, "90th_percentile": 341.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 388.97, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 388.97, "10th_percentile": 388.97, "90th_percentile": 388.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 371.06, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 371.06, "10th_percentile": 371.06, "90th_percentile": 371.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 273.94, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 273.94, "10th_percentile": 273.94, "90th_percentile": 273.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 327.98, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 327.98, "10th_percentile": 327.98, "90th_percentile": 327.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 213.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 213.25, "10th_percentile": 213.25, "90th_percentile": 213.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 255.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 255.9, "10th_percentile": 255.9, "90th_percentile": 255.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 426.5, "10th_percentile": 426.5, "90th_percentile": 426.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-33227", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65862-0502-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.86, "maximum": 20.0, "setting": "outpatient", "gross_charge": 20.0, "discounted_cash": 14.0, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8.22, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.22, "10th_percentile": 8.22, "90th_percentile": 8.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8.97, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.97, "10th_percentile": 8.97, "90th_percentile": 8.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.21, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.21, "10th_percentile": 8.21, "90th_percentile": 8.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 6.28, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 6.28, "10th_percentile": 6.28, "90th_percentile": 6.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 6.0, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.86, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 2.86, "10th_percentile": 2.86, "90th_percentile": 2.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 10.56, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.56, "10th_percentile": 10.56, "90th_percentile": 10.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 11.52, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.52, "10th_percentile": 11.52, "90th_percentile": 11.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 7.0, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8.97, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.97, "10th_percentile": 8.97, "90th_percentile": 8.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.21, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.21, "10th_percentile": 8.21, "90th_percentile": 8.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8.22, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.22, "10th_percentile": 8.22, "90th_percentile": 8.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.0, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.00 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.00 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.0, "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 $20.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "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 $20.00 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 4.28, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.28, "10th_percentile": 4.28, "90th_percentile": 4.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 13.38, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.38, "10th_percentile": 13.38, "90th_percentile": 13.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 11.48, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 11.48, "10th_percentile": 11.48, "90th_percentile": 11.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 16.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 10.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.0, "10th_percentile": 10.0, "90th_percentile": 10.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 8.26, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.26, "10th_percentile": 8.26, "90th_percentile": 8.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 10.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 10.0, "10th_percentile": 10.0, "90th_percentile": 10.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 15.32, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 15.32, "10th_percentile": 15.32, "90th_percentile": 15.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 17.4, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 17.4, "10th_percentile": 17.4, "90th_percentile": 17.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.0, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 12.85, "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": 12.85, "10th_percentile": 12.85, "90th_percentile": 12.85, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 18.24, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 18.24, "10th_percentile": 18.24, "90th_percentile": 18.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 15.38, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 15.38, "10th_percentile": 15.38, "90th_percentile": 15.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 10.04, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.04, "10th_percentile": 10.04, "90th_percentile": 10.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 12.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% 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 Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 20.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.0, "10th_percentile": 20.0, "90th_percentile": 20.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 73.11, "maximum": 511.25, "setting": "outpatient", "gross_charge": 511.25, "discounted_cash": 357.87, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 209.77, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.77, "10th_percentile": 209.77, "90th_percentile": 209.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 209.77, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.77, "10th_percentile": 209.77, "90th_percentile": 209.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 229.35, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.35, "10th_percentile": 229.35, "90th_percentile": 229.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 210.02, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 210.02, "10th_percentile": 210.02, "90th_percentile": 210.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 73.11, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 73.11, "10th_percentile": 73.11, "90th_percentile": 73.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 178.94, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 178.94, "10th_percentile": 178.94, "90th_percentile": 178.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 160.53, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 160.53, "10th_percentile": 160.53, "90th_percentile": 160.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 269.94, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.94, "10th_percentile": 269.94, "90th_percentile": 269.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 294.48, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 294.48, "10th_percentile": 294.48, "90th_percentile": 294.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 153.38, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 153.38, "10th_percentile": 153.38, "90th_percentile": 153.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 306.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 306.75, "10th_percentile": 306.75, "90th_percentile": 306.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 194.63, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.63, "10th_percentile": 194.63, "90th_percentile": 194.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 194.63, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.63, "10th_percentile": 194.63, "90th_percentile": 194.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 194.63, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.63, "10th_percentile": 194.63, "90th_percentile": 194.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 391.62, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 391.62, "10th_percentile": 391.62, "90th_percentile": 391.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 109.41, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.41, "10th_percentile": 109.41, "90th_percentile": 109.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 409.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 409.0, "10th_percentile": 409.0, "90th_percentile": 409.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 409.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 409.0, "10th_percentile": 409.0, "90th_percentile": 409.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 328.38, "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": 328.38, "10th_percentile": 328.38, "90th_percentile": 328.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 293.46, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 293.46, "10th_percentile": 293.46, "90th_percentile": 293.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 255.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 255.63, "10th_percentile": 255.63, "90th_percentile": 255.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 211.15, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 211.15, "10th_percentile": 211.15, "90th_percentile": 211.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 255.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 255.63, "10th_percentile": 255.63, "90th_percentile": 255.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 444.79, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 444.79, "10th_percentile": 444.79, "90th_percentile": 444.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 306.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 306.75, "10th_percentile": 306.75, "90th_percentile": 306.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 393.15, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 393.15, "10th_percentile": 393.15, "90th_percentile": 393.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 466.26, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 466.26, "10th_percentile": 466.26, "90th_percentile": 466.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 322.09, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 322.09, "10th_percentile": 322.09, "90th_percentile": 322.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 342.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 342.03, "10th_percentile": 342.03, "90th_percentile": 342.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 256.65, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 256.65, "10th_percentile": 256.65, "90th_percentile": 256.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 229.35, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.35, "10th_percentile": 229.35, "90th_percentile": 229.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 102.25, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 102.25, "10th_percentile": 102.25, "90th_percentile": 102.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 102.25, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 102.25, "10th_percentile": 102.25, "90th_percentile": 102.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 210.02, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 210.02, "10th_percentile": 210.02, "90th_percentile": 210.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 511.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 511.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 511.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 511.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $511.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $511.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 511.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $511.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $511.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 511.25, "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 $511.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "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 $511.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 511.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 306.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 306.75, "10th_percentile": 306.75, "90th_percentile": 306.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 306.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 306.75, "10th_percentile": 306.75, "90th_percentile": 306.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 194.63, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.63, "10th_percentile": 194.63, "90th_percentile": 194.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 511.25, "10th_percentile": 511.25, "90th_percentile": 511.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 3.29, "maximum": 47.75, "setting": "outpatient", "gross_charge": 47.75, "discounted_cash": 33.42, "payers_information": [ { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47.75 @ 11.5% = $5.49 due to $0.00 Claim Price", "median_amount": 5.49, "10th_percentile": 5.49, "90th_percentile": 5.49, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47.75 @ 11.5% = $5.49 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47.75 @ 11.5% = $5.49 due to $0.00 Claim Price", "median_amount": 5.49, "10th_percentile": 5.49, "90th_percentile": 5.49, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47.75 @ 11.5% = $5.49 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.3, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.3, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.3, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.3, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.3, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.3, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.29, "10th_percentile": 3.29, "90th_percentile": 3.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.29, "10th_percentile": 3.29, "90th_percentile": 3.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.29, "10th_percentile": 3.29, "90th_percentile": 3.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 19.62, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.62, "10th_percentile": 19.62, "90th_percentile": 19.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 19.62, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.62, "10th_percentile": 19.62, "90th_percentile": 19.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8.4, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.4, "10th_percentile": 8.4, "90th_percentile": 8.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8.4, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.4, "10th_percentile": 8.4, "90th_percentile": 8.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.83, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 16.71, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 16.71, "10th_percentile": 16.71, "90th_percentile": 16.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 14.33, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 14.33, "10th_percentile": 14.33, "90th_percentile": 14.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 14.99, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 14.99, "10th_percentile": 14.99, "90th_percentile": 14.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 27.41, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 27.41, "10th_percentile": 27.41, "90th_percentile": 27.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 30.08, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 30.08, "10th_percentile": 30.08, "90th_percentile": 30.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 28.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 28.65, "10th_percentile": 28.65, "90th_percentile": 28.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 36.72, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 36.72, "10th_percentile": 36.72, "90th_percentile": 36.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 43.55, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 43.55, "10th_percentile": 43.55, "90th_percentile": 43.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 38.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 38.2, "10th_percentile": 38.2, "90th_percentile": 38.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 41.54, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 41.54, "10th_percentile": 41.54, "90th_percentile": 41.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 38.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 38.2, "10th_percentile": 38.2, "90th_percentile": 38.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 23.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 23.88, "10th_percentile": 23.88, "90th_percentile": 23.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 36.58, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 36.58, "10th_percentile": 36.58, "90th_percentile": 36.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 23.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.88, "10th_percentile": 23.88, "90th_percentile": 23.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 47.75, "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 $47.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "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 $47.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47.75 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 47.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 47.75, "10th_percentile": 47.75, "90th_percentile": 47.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 28.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 28.65, "10th_percentile": 28.65, "90th_percentile": 28.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 28.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 28.65, "10th_percentile": 28.65, "90th_percentile": 28.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 28.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 28.65, "10th_percentile": 28.65, "90th_percentile": 28.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" } ] } ] }, { "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": 11.4, "maximum": 165.25, "setting": "outpatient", "gross_charge": 165.25, "discounted_cash": 115.67, "payers_information": [ { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $165.25 @ 11.5% = $19.00 due to $0.00 Claim Price", "median_amount": 19.0, "10th_percentile": 19.0, "90th_percentile": 19.0, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $165.25 @ 11.5% = $19.00 due to $0.00 Claim Price" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 99.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 99.15, "10th_percentile": 99.15, "90th_percentile": 99.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 99.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 99.15, "10th_percentile": 99.15, "90th_percentile": 99.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 11.4, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.4, "10th_percentile": 11.4, "90th_percentile": 11.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 11.4, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.4, "10th_percentile": 11.4, "90th_percentile": 11.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 94.85, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 94.85, "10th_percentile": 94.85, "90th_percentile": 94.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 150.71, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 150.71, "10th_percentile": 150.71, "90th_percentile": 150.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 132.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 132.2, "10th_percentile": 132.2, "90th_percentile": 132.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 82.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 82.63, "10th_percentile": 82.63, "90th_percentile": 82.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 99.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 99.15, "10th_percentile": 99.15, "90th_percentile": 99.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 127.08, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 127.08, "10th_percentile": 127.08, "90th_percentile": 127.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 104.11, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 104.11, "10th_percentile": 104.11, "90th_percentile": 104.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 143.77, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 143.77, "10th_percentile": 143.77, "90th_percentile": 143.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $165.25 @ 11.5% = $19.00 due to $0.00 Claim Price", "median_amount": 19.0, "10th_percentile": 19.0, "90th_percentile": 19.0, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $165.25 @ 11.5% = $19.00 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.34, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.34, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.34, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.34, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.34, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.34, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 99.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 99.15, "10th_percentile": 99.15, "90th_percentile": 99.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 165.25, "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 $165.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "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 $165.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $165.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $165.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $165.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $165.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 165.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 165.25, "10th_percentile": 165.25, "90th_percentile": 165.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 11.4, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.4, "10th_percentile": 11.4, "90th_percentile": 11.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 67.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.88, "10th_percentile": 67.88, "90th_percentile": 67.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 67.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.88, "10th_percentile": 67.88, "90th_percentile": 67.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 29.08, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.08, "10th_percentile": 29.08, "90th_percentile": 29.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 29.08, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.08, "10th_percentile": 29.08, "90th_percentile": 29.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 23.63, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 23.63, "10th_percentile": 23.63, "90th_percentile": 23.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 57.84, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 57.84, "10th_percentile": 57.84, "90th_percentile": 57.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 49.58, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 49.58, "10th_percentile": 49.58, "90th_percentile": 49.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 51.89, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 51.89, "10th_percentile": 51.89, "90th_percentile": 51.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 82.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.63, "10th_percentile": 82.63, "90th_percentile": 82.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 126.58, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 126.58, "10th_percentile": 126.58, "90th_percentile": 126.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 132.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 132.2, "10th_percentile": 132.2, "90th_percentile": 132.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "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": 43.58, "maximum": 631.66, "setting": "outpatient", "gross_charge": 631.66, "discounted_cash": 442.16, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 260.88, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.4, "10th_percentile": 353.4, "90th_percentile": 353.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 126.33, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 109.04, "10th_percentile": 109.04, "90th_percentile": 109.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 126.33, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 109.04, "10th_percentile": 109.04, "90th_percentile": 109.04, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $631.66 @ 11.5% = $72.64 due to $0.00 Claim Price", "median_amount": 72.64, "10th_percentile": 72.64, "90th_percentile": 72.64, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $631.66 @ 11.5% = $72.64 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $631.66 @ 11.5% = $72.64 due to $0.00 Claim Price", "median_amount": 72.64, "10th_percentile": 72.64, "90th_percentile": 72.64, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $631.66 @ 11.5% = $72.64 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 70.11, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 70.11, "10th_percentile": 70.11, "90th_percentile": 70.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 70.11, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 70.11, "10th_percentile": 70.11, "90th_percentile": 70.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 70.11, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 70.11, "10th_percentile": 70.11, "90th_percentile": 70.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 70.11, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 70.11, "10th_percentile": 70.11, "90th_percentile": 70.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 70.11, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 70.11, "10th_percentile": 70.11, "90th_percentile": 70.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 70.11, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 70.11, "10th_percentile": 70.11, "90th_percentile": 70.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 379.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 379.0, "10th_percentile": 379.0, "90th_percentile": 379.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 379.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 379.0, "10th_percentile": 379.0, "90th_percentile": 379.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 379.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 379.0, "10th_percentile": 379.0, "90th_percentile": 379.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $631.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $631.66 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $631.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $631.66 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $631.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $631.66 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 43.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.58, "10th_percentile": 43.58, "90th_percentile": 43.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 43.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.58, "10th_percentile": 43.58, "90th_percentile": 43.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 43.58, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.58, "10th_percentile": 43.58, "90th_percentile": 43.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 111.17, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.17, "10th_percentile": 111.17, "90th_percentile": 111.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 111.17, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.17, "10th_percentile": 111.17, "90th_percentile": 111.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 259.49, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 259.49, "10th_percentile": 259.49, "90th_percentile": 259.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 259.49, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 259.49, "10th_percentile": 259.49, "90th_percentile": 259.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 189.5, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 189.5, "10th_percentile": 189.5, "90th_percentile": 189.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 90.33, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 90.33, "10th_percentile": 90.33, "90th_percentile": 90.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 333.52, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 333.52, "10th_percentile": 333.52, "90th_percentile": 333.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 363.84, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.84, "10th_percentile": 363.84, "90th_percentile": 363.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 198.34, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 198.34, "10th_percentile": 198.34, "90th_percentile": 198.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 221.08, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 221.08, "10th_percentile": 221.08, "90th_percentile": 221.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 483.85, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 483.85, "10th_percentile": 483.85, "90th_percentile": 483.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 135.18, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.55, "10th_percentile": 186.55, "90th_percentile": 186.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 485.75, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 485.75, "10th_percentile": 485.75, "90th_percentile": 485.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 315.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 315.83, "10th_percentile": 315.83, "90th_percentile": 315.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 315.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.83, "10th_percentile": 315.83, "90th_percentile": 315.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 505.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 505.33, "10th_percentile": 505.33, "90th_percentile": 505.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 576.07, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 576.07, "10th_percentile": 576.07, "90th_percentile": 576.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 505.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 505.33, "10th_percentile": 505.33, "90th_percentile": 505.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 397.95, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 397.95, "10th_percentile": 397.95, "90th_percentile": 397.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 422.58, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 967.21, "10th_percentile": 967.21, "90th_percentile": 967.21, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 405.72, "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": 405.72, "10th_percentile": 405.72, "90th_percentile": 405.72, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 362.57, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 362.57, "10th_percentile": 362.57, "90th_percentile": 362.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 549.54, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 549.54, "10th_percentile": 549.54, "90th_percentile": 549.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 379.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 379.0, "10th_percentile": 379.0, "90th_percentile": 379.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 317.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.09, "10th_percentile": 317.09, "90th_percentile": 317.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 631.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 631.66, "10th_percentile": 631.66, "90th_percentile": 631.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 601.08, "maximum": 8711.32, "setting": "outpatient", "gross_charge": 8711.32, "discounted_cash": 6097.92, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3597.78, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.16, "10th_percentile": 82.16, "90th_percentile": 82.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 5827.87, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2288.54, "10th_percentile": 2288.54, "90th_percentile": 2288.54, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1245.72, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 48.93, "10th_percentile": 48.93, "90th_percentile": 48.93, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,711.32 @ 11.5% = $1,001.80 due to $0.00 Claim Price", "median_amount": 1001.8, "10th_percentile": 1001.8, "90th_percentile": 1001.8, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,711.32 @ 11.5% = $1,001.80 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,711.32 @ 11.5% = $1,001.80 due to $0.00 Claim Price", "median_amount": 1001.8, "10th_percentile": 1001.8, "90th_percentile": 1001.8, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,711.32 @ 11.5% = $1,001.80 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6699.01, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6699.01, "10th_percentile": 6699.01, "90th_percentile": 6699.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1864.22, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1864.22, "10th_percentile": 1864.22, "90th_percentile": 1864.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5488.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5488.13, "10th_percentile": 5488.13, "90th_percentile": 5488.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4355.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4355.66, "10th_percentile": 4355.66, "90th_percentile": 4355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6969.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6969.06, "10th_percentile": 6969.06, "90th_percentile": 6969.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 5000.3, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 5000.3, "10th_percentile": 5000.3, "90th_percentile": 5000.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6672.87, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6672.87, "10th_percentile": 6672.87, "90th_percentile": 6672.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7578.85, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7578.85, "10th_percentile": 7578.85, "90th_percentile": 7578.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5595.28, "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": 5595.28, "10th_percentile": 5595.28, "90th_percentile": 5595.28, "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": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4355.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4355.66, "10th_percentile": 4355.66, "90th_percentile": 4355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 6969.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 6969.06, "10th_percentile": 6969.06, "90th_percentile": 6969.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5226.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5226.79, "10th_percentile": 5226.79, "90th_percentile": 5226.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 7944.72, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7944.72, "10th_percentile": 7944.72, "90th_percentile": 7944.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4373.08, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4373.08, "10th_percentile": 4373.08, "90th_percentile": 4373.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4599.58, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4599.58, "10th_percentile": 4599.58, "90th_percentile": 4599.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 3048.96, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 3048.96, "10th_percentile": 3048.96, "90th_percentile": 3048.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2613.4, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2613.4, "10th_percentile": 2613.4, "90th_percentile": 2613.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2735.35, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2735.35, "10th_percentile": 2735.35, "90th_percentile": 2735.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 5017.72, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5017.72, "10th_percentile": 5017.72, "90th_percentile": 5017.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1533.19, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1533.19, "10th_percentile": 1533.19, "90th_percentile": 1533.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1533.19, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1533.19, "10th_percentile": 1533.19, "90th_percentile": 1533.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3578.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3578.61, "10th_percentile": 3578.61, "90th_percentile": 3578.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3578.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3578.61, "10th_percentile": 3578.61, "90th_percentile": 3578.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5226.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5226.79, "10th_percentile": 5226.79, "90th_percentile": 5226.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5226.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5226.79, "10th_percentile": 5226.79, "90th_percentile": 5226.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5226.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5226.79, "10th_percentile": 5226.79, "90th_percentile": 5226.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 601.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.08, "10th_percentile": 601.08, "90th_percentile": 601.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 601.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.08, "10th_percentile": 601.08, "90th_percentile": 601.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 601.08, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.08, "10th_percentile": 601.08, "90th_percentile": 601.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,711.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,711.32 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,711.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,711.32 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,711.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,711.32 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 8711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 8711.32, "10th_percentile": 8711.32, "90th_percentile": 8711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 966.96, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 966.96, "10th_percentile": 966.96, "90th_percentile": 966.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 966.96, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 966.96, "10th_percentile": 966.96, "90th_percentile": 966.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 966.96, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 966.96, "10th_percentile": 966.96, "90th_percentile": 966.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 966.96, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 966.96, "10th_percentile": 966.96, "90th_percentile": 966.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 966.96, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 966.96, "10th_percentile": 966.96, "90th_percentile": 966.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 966.96, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 966.96, "10th_percentile": 966.96, "90th_percentile": 966.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ANCHOR SUTURE KNTLS 1.8 FIBERTAK IMPLNT SYS", "code_information": [ { "code": "SUP-453219", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1008.51, "maximum": 14616.07, "setting": "outpatient", "gross_charge": 14616.07, "discounted_cash": 10231.25, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 2090.1, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 674.73, "10th_percentile": 674.73, "90th_percentile": 674.73, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 9778.15, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5270.68, "10th_percentile": 5270.68, "90th_percentile": 5270.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 6036.44, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.53, "10th_percentile": 768.53, "90th_percentile": 768.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1622.38, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 1622.38, "10th_percentile": 1622.38, "90th_percentile": 1622.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1622.38, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 1622.38, "10th_percentile": 1622.38, "90th_percentile": 1622.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1622.38, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 1622.38, "10th_percentile": 1622.38, "90th_percentile": 1622.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1622.38, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 1622.38, "10th_percentile": 1622.38, "90th_percentile": 1622.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1622.38, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 1622.38, "10th_percentile": 1622.38, "90th_percentile": 1622.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1622.38, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 1622.38, "10th_percentile": 1622.38, "90th_percentile": 1622.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 8769.64, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 8769.64, "10th_percentile": 8769.64, "90th_percentile": 8769.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 8769.64, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 8769.64, "10th_percentile": 8769.64, "90th_percentile": 8769.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 8769.64, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 8769.64, "10th_percentile": 8769.64, "90th_percentile": 8769.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1008.51, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.51, "10th_percentile": 1008.51, "90th_percentile": 1008.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1008.51, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.51, "10th_percentile": 1008.51, "90th_percentile": 1008.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1008.51, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.51, "10th_percentile": 1008.51, "90th_percentile": 1008.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 14616.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14616.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 14616.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 14616.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14,616.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14,616.07 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 14616.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14,616.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14,616.07 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14616.07, "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 $14,616.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "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 $14,616.07 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 14616.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2572.43, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2572.43, "10th_percentile": 2572.43, "90th_percentile": 2572.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2572.43, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2572.43, "10th_percentile": 2572.43, "90th_percentile": 2572.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 7308.04, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 7308.04, "10th_percentile": 7308.04, "90th_percentile": 7308.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 9387.9, "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": 9387.9, "10th_percentile": 9387.9, "90th_percentile": 9387.9, "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": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 11692.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 11692.86, "10th_percentile": 11692.86, "90th_percentile": 11692.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 11195.91, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 11195.91, "10th_percentile": 11195.91, "90th_percentile": 11195.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 8389.62, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 8389.62, "10th_percentile": 8389.62, "90th_percentile": 8389.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 8769.64, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 8769.64, "10th_percentile": 8769.64, "90th_percentile": 8769.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 12715.98, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 12715.98, "10th_percentile": 12715.98, "90th_percentile": 12715.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 11692.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 11692.86, "10th_percentile": 11692.86, "90th_percentile": 11692.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 3127.84, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3127.84, "10th_percentile": 3127.84, "90th_percentile": 3127.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 9208.12, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 9208.12, "10th_percentile": 9208.12, "90th_percentile": 9208.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 11239.76, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 11239.76, "10th_percentile": 11239.76, "90th_percentile": 11239.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 7337.27, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7337.27, "10th_percentile": 7337.27, "90th_percentile": 7337.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 7308.04, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7308.04, "10th_percentile": 7308.04, "90th_percentile": 7308.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 13329.86, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 13329.86, "10th_percentile": 13329.86, "90th_percentile": 13329.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 8418.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8418.86, "10th_percentile": 8418.86, "90th_percentile": 8418.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 7717.28, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7717.28, "10th_percentile": 7717.28, "90th_percentile": 7717.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 4589.45, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 4589.45, "10th_percentile": 4589.45, "90th_percentile": 4589.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 4384.82, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 4384.82, "10th_percentile": 4384.82, "90th_percentile": 4384.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 5115.62, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1346.65, "10th_percentile": 1346.65, "90th_percentile": 1346.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 2923.21, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 2923.21, "10th_percentile": 2923.21, "90th_percentile": 2923.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 2923.21, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 2923.21, "10th_percentile": 2923.21, "90th_percentile": 2923.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 6004.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6004.28, "10th_percentile": 6004.28, "90th_percentile": 6004.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 6004.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6004.28, "10th_percentile": 6004.28, "90th_percentile": 6004.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14,616.07 @ 11.5% = $1,680.85 due to $0.00 Claim Price", "median_amount": 1680.85, "10th_percentile": 1680.85, "90th_percentile": 1680.85, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14,616.07 @ 11.5% = $1,680.85 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14,616.07 @ 11.5% = $1,680.85 due to $0.00 Claim Price", "median_amount": 1680.85, "10th_percentile": 1680.85, "90th_percentile": 1680.85, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $14,616.07 @ 11.5% = $1,680.85 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14616.07, "10th_percentile": 14616.07, "90th_percentile": 14616.07, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ANES TEMPRERATURE PROBE SKIN", "code_information": [ { "code": "SUP-308891", "type": "CDM" }, { "code": "27000001", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 384.61, "maximum": 2689.59, "setting": "outpatient", "gross_charge": 2689.59, "discounted_cash": 1882.71, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1613.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1613.75, "10th_percentile": 1613.75, "90th_percentile": 1613.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1103.54, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1103.54, "10th_percentile": 1103.54, "90th_percentile": 1103.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1023.93, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1023.93, "10th_percentile": 1023.93, "90th_percentile": 1023.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1023.93, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1023.93, "10th_percentile": 1023.93, "90th_percentile": 1023.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1104.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1104.88, "10th_percentile": 1104.88, "90th_percentile": 1104.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2689.59, "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 $2,689.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "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 $2,689.59 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": "CDH BCBS PPO", "standard_charge_dollar": 1206.55, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1206.55, "10th_percentile": 1206.55, "90th_percentile": 1206.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 537.92, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 537.92, "10th_percentile": 537.92, "90th_percentile": 537.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2689.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,689.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,689.59 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2689.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,689.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,689.59 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2689.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2689.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1420.1, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1420.1, "10th_percentile": 1420.1, "90th_percentile": 1420.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 844.53, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 844.53, "10th_percentile": 844.53, "90th_percentile": 844.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1549.2, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1549.2, "10th_percentile": 1549.2, "90th_percentile": 1549.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 806.88, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 806.88, "10th_percentile": 806.88, "90th_percentile": 806.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 941.36, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 941.36, "10th_percentile": 941.36, "90th_percentile": 941.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 384.61, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 384.61, "10th_percentile": 384.61, "90th_percentile": 384.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1103.54, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1103.54, "10th_percentile": 1103.54, "90th_percentile": 1103.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1023.93, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1023.93, "10th_percentile": 1023.93, "90th_percentile": 1023.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1023.93, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1023.93, "10th_percentile": 1023.93, "90th_percentile": 1023.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1104.88, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1104.88, "10th_percentile": 1104.88, "90th_percentile": 1104.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1206.55, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1206.55, "10th_percentile": 1206.55, "90th_percentile": 1206.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1344.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1344.8, "10th_percentile": 1344.8, "90th_percentile": 1344.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2060.23, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2060.23, "10th_percentile": 2060.23, "90th_percentile": 2060.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 575.57, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 575.57, "10th_percentile": 575.57, "90th_percentile": 575.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2151.67, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2151.67, "10th_percentile": 2151.67, "90th_percentile": 2151.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1110.8, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1110.8, "10th_percentile": 1110.8, "90th_percentile": 1110.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2151.67, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2151.67, "10th_percentile": 2151.67, "90th_percentile": 2151.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1613.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1613.75, "10th_percentile": 1613.75, "90th_percentile": 1613.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2068.29, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2068.29, "10th_percentile": 2068.29, "90th_percentile": 2068.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 2452.91, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2452.91, "10th_percentile": 2452.91, "90th_percentile": 2452.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1344.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1344.8, "10th_percentile": 1344.8, "90th_percentile": 1344.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1694.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1694.44, "10th_percentile": 1694.44, "90th_percentile": 1694.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2689.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1613.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1613.75, "10th_percentile": 1613.75, "90th_percentile": 1613.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 537.92, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 537.92, "10th_percentile": 537.92, "90th_percentile": 537.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1613.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1613.75, "10th_percentile": 1613.75, "90th_percentile": 1613.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2339.94, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2339.94, "10th_percentile": 2339.94, "90th_percentile": 2339.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1543.82, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1543.82, "10th_percentile": 1543.82, "90th_percentile": 1543.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1727.52, "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": 1727.52, "10th_percentile": 1727.52, "90th_percentile": 1727.52, "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": "CDH UHC CORE", "standard_charge_dollar": 1350.17, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1350.17, "10th_percentile": 1350.17, "90th_percentile": 1350.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1799.34, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1799.34, "10th_percentile": 1799.34, "90th_percentile": 1799.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2689.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2689.59, "10th_percentile": 2689.59, "90th_percentile": 2689.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ANGIOPLASTY PACK LARGE BORE", "code_information": [ { "code": "SUP-11249", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 21.9, "maximum": 153.17, "setting": "outpatient", "gross_charge": 153.17, "discounted_cash": 107.22, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 58.31, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.31, "10th_percentile": 58.31, "90th_percentile": 58.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 58.31, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.31, "10th_percentile": 58.31, "90th_percentile": 58.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 58.31, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.31, "10th_percentile": 58.31, "90th_percentile": 58.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 58.31, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.31, "10th_percentile": 58.31, "90th_percentile": 58.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 68.71, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.71, "10th_percentile": 68.71, "90th_percentile": 68.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 91.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 91.9, "10th_percentile": 91.9, "90th_percentile": 91.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 62.92, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.92, "10th_percentile": 62.92, "90th_percentile": 62.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 30.63, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 30.63, "10th_percentile": 30.63, "90th_percentile": 30.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 62.85, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.85, "10th_percentile": 62.85, "90th_percentile": 62.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $153.17 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $153.17 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $153.17 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $153.17 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $153.17 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $153.17 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 91.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 91.9, "10th_percentile": 91.9, "90th_percentile": 91.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 91.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 91.9, "10th_percentile": 91.9, "90th_percentile": 91.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 45.95, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 45.95, "10th_percentile": 45.95, "90th_percentile": 45.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 53.61, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 53.61, "10th_percentile": 53.61, "90th_percentile": 53.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 88.23, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.23, "10th_percentile": 88.23, "90th_percentile": 88.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 21.9, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 21.9, "10th_percentile": 21.9, "90th_percentile": 21.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 80.87, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.87, "10th_percentile": 80.87, "90th_percentile": 80.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 48.1, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 48.1, "10th_percentile": 48.1, "90th_percentile": 48.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 153.17, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 62.85, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.85, "10th_percentile": 62.85, "90th_percentile": 62.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 62.92, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.92, "10th_percentile": 62.92, "90th_percentile": 62.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 30.63, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 30.63, "10th_percentile": 30.63, "90th_percentile": 30.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 102.47, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.47, "10th_percentile": 102.47, "90th_percentile": 102.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 76.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 76.59, "10th_percentile": 76.59, "90th_percentile": 76.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 76.89, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.89, "10th_percentile": 76.89, "90th_percentile": 76.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 87.92, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 87.92, "10th_percentile": 87.92, "90th_percentile": 87.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 117.33, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 117.33, "10th_percentile": 117.33, "90th_percentile": 117.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 68.71, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.71, "10th_percentile": 68.71, "90th_percentile": 68.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 96.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 96.5, "10th_percentile": 96.5, "90th_percentile": 96.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 32.78, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.78, "10th_percentile": 32.78, "90th_percentile": 32.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 122.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 122.54, "10th_percentile": 122.54, "90th_percentile": 122.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 63.26, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.26, "10th_percentile": 63.26, "90th_percentile": 63.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 122.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 122.54, "10th_percentile": 122.54, "90th_percentile": 122.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 98.38, "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": 98.38, "10th_percentile": 98.38, "90th_percentile": 98.38, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 91.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 91.9, "10th_percentile": 91.9, "90th_percentile": 91.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 139.69, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 139.69, "10th_percentile": 139.69, "90th_percentile": 139.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 133.26, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 133.26, "10th_percentile": 133.26, "90th_percentile": 133.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 117.79, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 117.79, "10th_percentile": 117.79, "90th_percentile": 117.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 76.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.59, "10th_percentile": 76.59, "90th_percentile": 76.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 153.17, "10th_percentile": 153.17, "90th_percentile": 153.17, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 2833.44, "maximum": 41064.32, "setting": "outpatient", "gross_charge": 41064.32, "discounted_cash": 28745.02, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 27472.03, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2288.54, "10th_percentile": 2288.54, "90th_percentile": 2288.54, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 16959.56, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.16, "10th_percentile": 82.16, "90th_percentile": 82.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4558.14, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4558.14, "10th_percentile": 4558.14, "90th_percentile": 4558.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4558.14, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4558.14, "10th_percentile": 4558.14, "90th_percentile": 4558.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4558.14, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4558.14, "10th_percentile": 4558.14, "90th_percentile": 4558.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $41,064.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $41,064.32 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $41,064.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $41,064.32 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $41,064.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $41,064.32 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 41064.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 24638.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 24638.59, "10th_percentile": 24638.59, "90th_percentile": 24638.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 24638.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 24638.59, "10th_percentile": 24638.59, "90th_percentile": 24638.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 24638.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 24638.59, "10th_percentile": 24638.59, "90th_percentile": 24638.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2833.44, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2833.44, "10th_percentile": 2833.44, "90th_percentile": 2833.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2833.44, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2833.44, "10th_percentile": 2833.44, "90th_percentile": 2833.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2833.44, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2833.44, "10th_percentile": 2833.44, "90th_percentile": 2833.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 7227.32, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7227.32, "10th_percentile": 7227.32, "90th_percentile": 7227.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 7227.32, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7227.32, "10th_percentile": 7227.32, "90th_percentile": 7227.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 16869.22, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16869.22, "10th_percentile": 16869.22, "90th_percentile": 16869.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 32851.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 32851.46, "10th_percentile": 32851.46, "90th_percentile": 32851.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 20532.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20532.16, "10th_percentile": 20532.16, "90th_percentile": 20532.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 35725.96, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 35725.96, "10th_percentile": 35725.96, "90th_percentile": 35725.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 23570.92, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 23570.92, "10th_percentile": 23570.92, "90th_percentile": 23570.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 20614.29, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20614.29, "10th_percentile": 20614.29, "90th_percentile": 20614.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 20532.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 20532.16, "10th_percentile": 20532.16, "90th_percentile": 20532.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 26375.61, "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": 26375.61, "10th_percentile": 26375.61, "90th_percentile": 26375.61, "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": "CDH HFN", "standard_charge_dollar": 37450.66, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 37450.66, "10th_percentile": 37450.66, "90th_percentile": 37450.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 31578.46, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 31578.46, "10th_percentile": 31578.46, "90th_percentile": 31578.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 8787.76, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8787.76, "10th_percentile": 8787.76, "90th_percentile": 8787.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 31455.27, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 31455.27, "10th_percentile": 31455.27, "90th_percentile": 31455.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 24638.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 24638.59, "10th_percentile": 24638.59, "90th_percentile": 24638.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 32851.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 32851.46, "10th_percentile": 32851.46, "90th_percentile": 32851.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 25870.52, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 25870.52, "10th_percentile": 25870.52, "90th_percentile": 25870.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $41,064.32 @ 11.5% = $4,722.40 due to $0.00 Claim Price", "median_amount": 4722.4, "10th_percentile": 4722.4, "90th_percentile": 4722.4, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $41,064.32 @ 11.5% = $4,722.40 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 41064.32, "10th_percentile": 41064.32, "90th_percentile": 41064.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 5872.2, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 48.93, "10th_percentile": 48.93, "90th_percentile": 48.93, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4558.14, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4558.14, "10th_percentile": 4558.14, "90th_percentile": 4558.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4558.14, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4558.14, "10th_percentile": 4558.14, "90th_percentile": 4558.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4558.14, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 4558.14, "10th_percentile": 4558.14, "90th_percentile": 4558.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 16869.22, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16869.22, "10th_percentile": 16869.22, "90th_percentile": 16869.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 21681.96, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21681.96, "10th_percentile": 21681.96, "90th_percentile": 21681.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 12894.2, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 12894.2, "10th_percentile": 12894.2, "90th_percentile": 12894.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 14372.51, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 14372.51, "10th_percentile": 14372.51, "90th_percentile": 14372.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 23653.05, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23653.05, "10th_percentile": 23653.05, "90th_percentile": 23653.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 12319.3, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 12319.3, "10th_percentile": 12319.3, "90th_percentile": 12319.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $41,064.32 @ 11.5% = $4,722.40 due to $0.00 Claim Price", "median_amount": 4722.4, "10th_percentile": 4722.4, "90th_percentile": 4722.4, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $41,064.32 @ 11.5% = $4,722.40 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": 19030.64, "setting": "inpatient", "gross_charge": 68047.54, "discounted_cash": 47633.28, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 41656.83, "10th_percentile": 41656.83, "90th_percentile": 41656.83, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 41656.83, "10th_percentile": 41656.83, "90th_percentile": 41656.83, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 41656.83, "10th_percentile": 41656.83, "90th_percentile": 41656.83, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 60402.4, "10th_percentile": 60402.4, "90th_percentile": 60402.4, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 40545.97, "10th_percentile": 40545.97, "90th_percentile": 40545.97, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 55542.43, "10th_percentile": 55542.43, "90th_percentile": 55542.43, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 34714.03, "10th_percentile": 34714.03, "90th_percentile": 34714.03, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 34714.03, "10th_percentile": 34714.03, "90th_percentile": 34714.03, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; IP Services; 92% Billed", "median_amount": 63873.8, "10th_percentile": 63873.8, "90th_percentile": 63873.8, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; 92% Billed", "median_amount": 63873.8, "10th_percentile": 63873.8, "90th_percentile": 63873.8, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All Inpatient Services; 75.1% Billed", "median_amount": 52140.46, "10th_percentile": 52140.46, "90th_percentile": 52140.46, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient Services; 63% Billed", "median_amount": 43739.67, "10th_percentile": 43739.67, "90th_percentile": 43739.67, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20134.13, "10th_percentile": 20134.13, "90th_percentile": 20134.13, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; 100% Billed", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services - OON; 100% Billed", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 69428.04, "10th_percentile": 69428.04, "90th_percentile": 69428.04, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 19030.64, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 53730.85, "10th_percentile": 53730.85, "90th_percentile": 53730.85, "count": "36", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14354.54, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14354.54, "10th_percentile": 14354.54, "90th_percentile": 14354.54, "count": "36", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 12116.65, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 82154.0, "10th_percentile": 82154.0, "90th_percentile": 82154.0, "count": "36", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 12116.65, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 82154.0, "10th_percentile": 82154.0, "90th_percentile": 82154.0, "count": "36", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 19030.64, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 53730.85, "10th_percentile": 53730.85, "90th_percentile": 53730.85, "count": "36", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15646.9, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15646.9, "10th_percentile": 15646.9, "90th_percentile": 15646.9, "count": "36", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15216.5, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15216.5, "10th_percentile": 15216.5, "90th_percentile": 15216.5, "count": "36", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14354.54, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 14354.54, "10th_percentile": 14354.54, "90th_percentile": 14354.54, "count": "36", "methodology": "case rate" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; 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: $8,759.33; Total: $8,759.33 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8759.33, "10th_percentile": 8759.33, "90th_percentile": 8759.33, "count": "36", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; 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: $8,759.33; Total: $8,759.33 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $10,424.62; Percentage applied: 97.00%; Total: $10,111.88 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10111.88, "10th_percentile": 10111.88, "90th_percentile": 10111.88, "count": "36", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $10,424.62; Percentage applied: 97.00%; Total: $10,111.88 Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,424.62; Total: $10,424.62", "median_amount": 10424.62, "10th_percentile": 10424.62, "90th_percentile": 10424.62, "count": "36", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,424.62; Total: $10,424.62" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All Inpatient Services; 37% Billed", "median_amount": 25688.37, "10th_percentile": 25688.37, "90th_percentile": 25688.37, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; 30% Billed", "median_amount": 20828.41, "10th_percentile": 20828.41, "90th_percentile": 20828.41, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All Inpatient Services; 32.6% Billed", "median_amount": 22633.54, "10th_percentile": 22633.54, "90th_percentile": 22633.54, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 9928.22, "10th_percentile": 9928.22, "90th_percentile": 9928.22, "count": "36", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15646.9, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15646.9, "10th_percentile": 15646.9, "90th_percentile": 15646.9, "count": "36", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15216.5, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 15216.5, "10th_percentile": 15216.5, "90th_percentile": 15216.5, "count": "36", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,424.62; Total: $10,424.62", "median_amount": 10424.62, "10th_percentile": 10424.62, "90th_percentile": 10424.62, "count": "36", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764146667; Using historical claim(s); Scope: All Financial Classes; Cases: 36; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $10,424.62; Total: $10,424.62" } ] } ] }, { "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": 122.34, "maximum": 1773.0, "setting": "outpatient", "gross_charge": 1773.0, "discounted_cash": 1241.1, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,773.00 @ 11.5% = $203.90 due to $0.00 Claim Price", "median_amount": 203.9, "10th_percentile": 203.9, "90th_percentile": 203.9, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,773.00 @ 11.5% = $203.90 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 196.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 196.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 196.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 196.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 196.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 196.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1063.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1063.8, "10th_percentile": 1063.8, "90th_percentile": 1063.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1063.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1063.8, "10th_percentile": 1063.8, "90th_percentile": 1063.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 122.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.34, "10th_percentile": 122.34, "90th_percentile": 122.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 122.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.34, "10th_percentile": 122.34, "90th_percentile": 122.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1773.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,773.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,773.00 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1773.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,773.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,773.00 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1773.0, "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 $1,773.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,773.00 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1773.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 728.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 728.35, "10th_percentile": 728.35, "90th_percentile": 728.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 728.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 728.35, "10th_percentile": 728.35, "90th_percentile": 728.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 312.05, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 312.05, "10th_percentile": 312.05, "90th_percentile": 312.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 312.05, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 312.05, "10th_percentile": 312.05, "90th_percentile": 312.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 253.54, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 253.54, "10th_percentile": 253.54, "90th_percentile": 253.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 620.55, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 620.55, "10th_percentile": 620.55, "90th_percentile": 620.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 531.9, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 531.9, "10th_percentile": 531.9, "90th_percentile": 531.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 556.72, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 556.72, "10th_percentile": 556.72, "90th_percentile": 556.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 886.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 886.5, "10th_percentile": 886.5, "90th_percentile": 886.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 1358.12, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1358.12, "10th_percentile": 1358.12, "90th_percentile": 1358.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1418.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1418.4, "10th_percentile": 1418.4, "90th_percentile": 1418.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1418.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1418.4, "10th_percentile": 1418.4, "90th_percentile": 1418.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 354.6, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 354.6, "10th_percentile": 354.6, "90th_percentile": 354.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,773.00 @ 11.5% = $203.90 due to $0.00 Claim Price", "median_amount": 203.9, "10th_percentile": 203.9, "90th_percentile": 203.9, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,773.00 @ 11.5% = $203.90 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1773.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1773.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1773.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1773.0, "10th_percentile": 1773.0, "90th_percentile": 1773.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1063.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1063.8, "10th_percentile": 1063.8, "90th_percentile": 1063.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 122.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.34, "10th_percentile": 122.34, "90th_percentile": 122.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1017.7, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1017.7, "10th_percentile": 1017.7, "90th_percentile": 1017.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1063.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1063.8, "10th_percentile": 1063.8, "90th_percentile": 1063.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1363.44, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1363.44, "10th_percentile": 1363.44, "90th_percentile": 1363.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1542.51, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1542.51, "10th_percentile": 1542.51, "90th_percentile": 1542.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1616.98, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1616.98, "10th_percentile": 1616.98, "90th_percentile": 1616.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1116.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1116.99, "10th_percentile": 1116.99, "90th_percentile": 1116.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 886.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 886.5, "10th_percentile": 886.5, "90th_percentile": 886.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 354.6, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 354.6, "10th_percentile": 354.6, "90th_percentile": 354.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" } ] } ] }, { "description": "ARTERIAL LINE TRANSDUCER SINGLE", "code_information": [ { "code": "SUP-303387", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 34.86, "maximum": 243.81, "setting": "outpatient", "gross_charge": 243.81, "discounted_cash": 170.67, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 92.82, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.82, "10th_percentile": 92.82, "90th_percentile": 92.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 92.82, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.82, "10th_percentile": 92.82, "90th_percentile": 92.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 92.82, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.82, "10th_percentile": 92.82, "90th_percentile": 92.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 92.82, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.82, "10th_percentile": 92.82, "90th_percentile": 92.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 109.37, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.37, "10th_percentile": 109.37, "90th_percentile": 109.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 146.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 146.29, "10th_percentile": 146.29, "90th_percentile": 146.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 100.16, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.16, "10th_percentile": 100.16, "90th_percentile": 100.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 48.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 48.76, "10th_percentile": 48.76, "90th_percentile": 48.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 100.04, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.04, "10th_percentile": 100.04, "90th_percentile": 100.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 243.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $243.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $243.81 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 243.81, "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 $243.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "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 $243.81 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 243.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $243.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $243.81 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 243.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 146.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 146.29, "10th_percentile": 146.29, "90th_percentile": 146.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 146.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 146.29, "10th_percentile": 146.29, "90th_percentile": 146.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 73.14, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 73.14, "10th_percentile": 73.14, "90th_percentile": 73.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 85.33, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 85.33, "10th_percentile": 85.33, "90th_percentile": 85.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 34.86, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 34.86, "10th_percentile": 34.86, "90th_percentile": 34.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 243.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 243.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 243.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 100.04, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.04, "10th_percentile": 100.04, "90th_percentile": 100.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 100.16, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.16, "10th_percentile": 100.16, "90th_percentile": 100.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 48.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 48.76, "10th_percentile": 48.76, "90th_percentile": 48.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 163.11, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 163.11, "10th_percentile": 163.11, "90th_percentile": 163.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 121.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 121.91, "10th_percentile": 121.91, "90th_percentile": 121.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 122.39, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.39, "10th_percentile": 122.39, "90th_percentile": 122.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 139.95, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 139.95, "10th_percentile": 139.95, "90th_percentile": 139.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 186.76, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 186.76, "10th_percentile": 186.76, "90th_percentile": 186.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 109.37, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.37, "10th_percentile": 109.37, "90th_percentile": 109.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 153.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 153.6, "10th_percentile": 153.6, "90th_percentile": 153.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 52.18, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.18, "10th_percentile": 52.18, "90th_percentile": 52.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 195.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 195.05, "10th_percentile": 195.05, "90th_percentile": 195.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 100.69, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.69, "10th_percentile": 100.69, "90th_percentile": 100.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 195.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 195.05, "10th_percentile": 195.05, "90th_percentile": 195.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 156.6, "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": 156.6, "10th_percentile": 156.6, "90th_percentile": 156.6, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 146.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 146.29, "10th_percentile": 146.29, "90th_percentile": 146.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 222.35, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 222.35, "10th_percentile": 222.35, "90th_percentile": 222.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 212.11, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 212.11, "10th_percentile": 212.11, "90th_percentile": 212.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 187.49, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 187.49, "10th_percentile": 187.49, "90th_percentile": 187.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 121.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.91, "10th_percentile": 121.91, "90th_percentile": 121.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 76.56, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 76.56, "10th_percentile": 76.56, "90th_percentile": 76.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 140.43, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.43, "10th_percentile": 140.43, "90th_percentile": 140.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 128.73, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.73, "10th_percentile": 128.73, "90th_percentile": 128.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": 14.34, "maximum": 100.27, "setting": "outpatient", "gross_charge": 100.27, "discounted_cash": 70.19, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 60.16, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 60.16, "10th_percentile": 60.16, "90th_percentile": 60.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 44.98, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.98, "10th_percentile": 44.98, "90th_percentile": 44.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 41.19, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.19, "10th_percentile": 41.19, "90th_percentile": 41.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 20.05, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 20.05, "10th_percentile": 20.05, "90th_percentile": 20.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 41.14, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.14, "10th_percentile": 41.14, "90th_percentile": 41.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 100.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $100.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $100.27 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 100.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $100.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $100.27 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 100.27, "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 $100.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "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 $100.27 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 100.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% 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 Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.17, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.17, "10th_percentile": 38.17, "90th_percentile": 38.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.17, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.17, "10th_percentile": 38.17, "90th_percentile": 38.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 52.94, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.94, "10th_percentile": 52.94, "90th_percentile": 52.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 57.76, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.76, "10th_percentile": 57.76, "90th_percentile": 57.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 31.48, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 31.48, "10th_percentile": 31.48, "90th_percentile": 31.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 30.08, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 30.08, "10th_percentile": 30.08, "90th_percentile": 30.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 14.34, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 14.34, "10th_percentile": 14.34, "90th_percentile": 14.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 35.09, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 35.09, "10th_percentile": 35.09, "90th_percentile": 35.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 100.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% 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 OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 100.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 100.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 50.34, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.34, "10th_percentile": 50.34, "90th_percentile": 50.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 77.11, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 77.11, "10th_percentile": 77.11, "90th_percentile": 77.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 64.4, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 64.4, "10th_percentile": 64.4, "90th_percentile": 64.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 67.08, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.08, "10th_percentile": 67.08, "90th_percentile": 67.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 91.45, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 91.45, "10th_percentile": 91.45, "90th_percentile": 91.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 80.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 80.22, "10th_percentile": 80.22, "90th_percentile": 80.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 41.19, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.19, "10th_percentile": 41.19, "90th_percentile": 41.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 57.55, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 57.55, "10th_percentile": 57.55, "90th_percentile": 57.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 60.16, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 60.16, "10th_percentile": 60.16, "90th_percentile": 60.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 50.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.14, "10th_percentile": 50.14, "90th_percentile": 50.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 80.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 80.22, "10th_percentile": 80.22, "90th_percentile": 80.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 41.14, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.14, "10th_percentile": 41.14, "90th_percentile": 41.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 20.05, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 20.05, "10th_percentile": 20.05, "90th_percentile": 20.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 21.46, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.46, "10th_percentile": 21.46, "90th_percentile": 21.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 87.23, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 87.23, "10th_percentile": 87.23, "90th_percentile": 87.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 41.41, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.41, "10th_percentile": 41.41, "90th_percentile": 41.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 76.81, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 76.81, "10th_percentile": 76.81, "90th_percentile": 76.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 50.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 50.14, "10th_percentile": 50.14, "90th_percentile": 50.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 63.17, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 63.17, "10th_percentile": 63.17, "90th_percentile": 63.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 44.98, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.98, "10th_percentile": 44.98, "90th_percentile": 44.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 60.16, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 60.16, "10th_percentile": 60.16, "90th_percentile": 60.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 60.16, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 60.16, "10th_percentile": 60.16, "90th_percentile": 60.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.17, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.17, "10th_percentile": 38.17, "90th_percentile": 38.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.17, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.17, "10th_percentile": 38.17, "90th_percentile": 38.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 96.6, "maximum": 675.5, "setting": "outpatient", "gross_charge": 675.5, "discounted_cash": 472.85, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 675.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 675.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 675.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 339.1, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 339.1, "10th_percentile": 339.1, "90th_percentile": 339.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 519.46, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 519.46, "10th_percentile": 519.46, "90th_percentile": 519.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 433.87, "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": 433.87, "10th_percentile": 433.87, "90th_percentile": 433.87, "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": "CDH UHC HMO/PPO", "standard_charge_dollar": 451.91, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 451.91, "10th_percentile": 451.91, "90th_percentile": 451.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 616.06, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 616.06, "10th_percentile": 616.06, "90th_percentile": 616.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 387.74, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 387.74, "10th_percentile": 387.74, "90th_percentile": 387.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 405.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 405.3, "10th_percentile": 405.3, "90th_percentile": 405.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 135.1, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 135.1, "10th_percentile": 135.1, "90th_percentile": 135.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 587.69, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 587.69, "10th_percentile": 587.69, "90th_percentile": 587.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 337.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 337.75, "10th_percentile": 337.75, "90th_percentile": 337.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 425.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 425.57, "10th_percentile": 425.57, "90th_percentile": 425.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 405.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 405.3, "10th_percentile": 405.3, "90th_percentile": 405.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 257.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.16, "10th_percentile": 257.16, "90th_percentile": 257.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 257.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.16, "10th_percentile": 257.16, "90th_percentile": 257.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 257.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.16, "10th_percentile": 257.16, "90th_percentile": 257.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 257.16, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.16, "10th_percentile": 257.16, "90th_percentile": 257.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 303.03, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 303.03, "10th_percentile": 303.03, "90th_percentile": 303.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 405.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 405.3, "10th_percentile": 405.3, "90th_percentile": 405.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 277.5, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.5, "10th_percentile": 277.5, "90th_percentile": 277.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 135.1, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 135.1, "10th_percentile": 135.1, "90th_percentile": 135.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 277.16, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.16, "10th_percentile": 277.16, "90th_percentile": 277.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 675.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $675.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $675.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 675.5, "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 $675.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "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 $675.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 675.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $675.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $675.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 675.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 405.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 405.3, "10th_percentile": 405.3, "90th_percentile": 405.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 202.65, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 202.65, "10th_percentile": 202.65, "90th_percentile": 202.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 236.43, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 236.43, "10th_percentile": 236.43, "90th_percentile": 236.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 389.09, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 389.09, "10th_percentile": 389.09, "90th_percentile": 389.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 96.6, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 96.6, "10th_percentile": 96.6, "90th_percentile": 96.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 356.66, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.66, "10th_percentile": 356.66, "90th_percentile": 356.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 212.11, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 212.11, "10th_percentile": 212.11, "90th_percentile": 212.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 277.16, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.16, "10th_percentile": 277.16, "90th_percentile": 277.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 277.5, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.5, "10th_percentile": 277.5, "90th_percentile": 277.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 517.43, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 517.43, "10th_percentile": 517.43, "90th_percentile": 517.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 303.03, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 303.03, "10th_percentile": 303.03, "90th_percentile": 303.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 144.56, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144.56, "10th_percentile": 144.56, "90th_percentile": 144.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 540.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 540.4, "10th_percentile": 540.4, "90th_percentile": 540.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 278.98, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 278.98, "10th_percentile": 278.98, "90th_percentile": 278.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 540.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 540.4, "10th_percentile": 540.4, "90th_percentile": 540.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 337.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 337.75, "10th_percentile": 337.75, "90th_percentile": 337.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 675.5, "10th_percentile": 675.5, "90th_percentile": 675.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 555.5, "maximum": 3884.65, "setting": "outpatient", "gross_charge": 3884.65, "discounted_cash": 2719.25, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2598.83, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2598.83, "10th_percentile": 2598.83, "90th_percentile": 2598.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1950.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1950.09, "10th_percentile": 1950.09, "90th_percentile": 1950.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2229.79, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2229.79, "10th_percentile": 2229.79, "90th_percentile": 2229.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2495.11, "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": 2495.11, "10th_percentile": 2495.11, "90th_percentile": 2495.11, "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": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1478.89, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1478.89, "10th_percentile": 1478.89, "90th_percentile": 1478.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1478.89, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1478.89, "10th_percentile": 1478.89, "90th_percentile": 1478.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1478.89, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1478.89, "10th_percentile": 1478.89, "90th_percentile": 1478.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1478.89, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1478.89, "10th_percentile": 1478.89, "90th_percentile": 1478.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2330.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2330.79, "10th_percentile": 2330.79, "90th_percentile": 2330.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2330.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2330.79, "10th_percentile": 2330.79, "90th_percentile": 2330.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2330.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2330.79, "10th_percentile": 2330.79, "90th_percentile": 2330.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,884.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,884.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,884.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,884.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,884.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,884.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3884.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1219.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1219.78, "10th_percentile": 1219.78, "90th_percentile": 1219.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2237.56, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2237.56, "10th_percentile": 2237.56, "90th_percentile": 2237.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 555.5, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 555.5, "10th_percentile": 555.5, "90th_percentile": 555.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1165.4, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1165.4, "10th_percentile": 1165.4, "90th_percentile": 1165.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1359.63, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1359.63, "10th_percentile": 1359.63, "90th_percentile": 1359.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2051.1, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2051.1, "10th_percentile": 2051.1, "90th_percentile": 2051.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1593.87, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1593.87, "10th_percentile": 1593.87, "90th_percentile": 1593.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1593.87, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1593.87, "10th_percentile": 1593.87, "90th_percentile": 1593.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 776.93, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 776.93, "10th_percentile": 776.93, "90th_percentile": 776.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 776.93, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 776.93, "10th_percentile": 776.93, "90th_percentile": 776.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1595.81, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1595.81, "10th_percentile": 1595.81, "90th_percentile": 1595.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1595.81, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1595.81, "10th_percentile": 1595.81, "90th_percentile": 1595.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1742.65, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1742.65, "10th_percentile": 1742.65, "90th_percentile": 1742.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1742.65, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1742.65, "10th_percentile": 1742.65, "90th_percentile": 1742.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2330.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2330.79, "10th_percentile": 2330.79, "90th_percentile": 2330.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3542.8, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3542.8, "10th_percentile": 3542.8, "90th_percentile": 3542.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1604.36, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1604.36, "10th_percentile": 1604.36, "90th_percentile": 1604.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3107.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3107.72, "10th_percentile": 3107.72, "90th_percentile": 3107.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1942.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1942.33, "10th_percentile": 1942.33, "90th_percentile": 1942.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 831.32, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 831.32, "10th_percentile": 831.32, "90th_percentile": 831.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3379.65, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3379.65, "10th_percentile": 3379.65, "90th_percentile": 3379.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2447.33, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2447.33, "10th_percentile": 2447.33, "90th_percentile": 2447.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2987.3, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2987.3, "10th_percentile": 2987.3, "90th_percentile": 2987.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2975.64, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2975.64, "10th_percentile": 2975.64, "90th_percentile": 2975.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 3107.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 3107.72, "10th_percentile": 3107.72, "90th_percentile": 3107.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1942.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1942.33, "10th_percentile": 1942.33, "90th_percentile": 1942.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3884.65, "10th_percentile": 3884.65, "90th_percentile": 3884.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": "00456-2405-60", "type": "NDC" } ], "standard_charges": [ { "minimum": 70.53, "maximum": 493.25, "setting": "outpatient", "gross_charge": 493.25, "discounted_cash": 345.27, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "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": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 187.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.78, "10th_percentile": 187.78, "90th_percentile": 187.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 187.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.78, "10th_percentile": 187.78, "90th_percentile": 187.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 295.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 295.95, "10th_percentile": 295.95, "90th_percentile": 295.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 295.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 295.95, "10th_percentile": 295.95, "90th_percentile": 295.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 283.13, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 283.13, "10th_percentile": 283.13, "90th_percentile": 283.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 246.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 246.63, "10th_percentile": 246.63, "90th_percentile": 246.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 449.84, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 449.84, "10th_percentile": 449.84, "90th_percentile": 449.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 246.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 246.63, "10th_percentile": 246.63, "90th_percentile": 246.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 429.13, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 429.13, "10th_percentile": 429.13, "90th_percentile": 429.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 379.31, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 379.31, "10th_percentile": 379.31, "90th_percentile": 379.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 105.56, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.56, "10th_percentile": 105.56, "90th_percentile": 105.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 394.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 394.6, "10th_percentile": 394.6, "90th_percentile": 394.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 310.75, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 310.75, "10th_percentile": 310.75, "90th_percentile": 310.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 377.83, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 377.83, "10th_percentile": 377.83, "90th_percentile": 377.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 316.81, "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": 316.81, "10th_percentile": 316.81, "90th_percentile": 316.81, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 295.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 295.95, "10th_percentile": 295.95, "90th_percentile": 295.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 203.71, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.71, "10th_percentile": 203.71, "90th_percentile": 203.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 329.98, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.98, "10th_percentile": 329.98, "90th_percentile": 329.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 394.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 394.6, "10th_percentile": 394.6, "90th_percentile": 394.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 247.61, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.61, "10th_percentile": 247.61, "90th_percentile": 247.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 98.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 98.65, "10th_percentile": 98.65, "90th_percentile": 98.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 98.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 98.65, "10th_percentile": 98.65, "90th_percentile": 98.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 202.38, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.38, "10th_percentile": 202.38, "90th_percentile": 202.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 202.63, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.63, "10th_percentile": 202.63, "90th_percentile": 202.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 221.27, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.27, "10th_percentile": 221.27, "90th_percentile": 221.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 493.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 493.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 493.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 493.25, "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 $493.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "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 $493.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 493.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $493.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $493.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 493.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $493.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $493.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 493.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 493.25, "10th_percentile": 493.25, "90th_percentile": 493.25, "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": "CDH ADVOCATE IPA", "standard_charge_dollar": 295.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 295.95, "10th_percentile": 295.95, "90th_percentile": 295.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 202.38, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.38, "10th_percentile": 202.38, "90th_percentile": 202.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 221.27, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.27, "10th_percentile": 221.27, "90th_percentile": 221.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 202.63, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.63, "10th_percentile": 202.63, "90th_percentile": 202.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 70.53, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 70.53, "10th_percentile": 70.53, "90th_percentile": 70.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 154.88, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 154.88, "10th_percentile": 154.88, "90th_percentile": 154.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 260.44, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 260.44, "10th_percentile": 260.44, "90th_percentile": 260.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 284.11, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 284.11, "10th_percentile": 284.11, "90th_percentile": 284.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 147.98, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 147.98, "10th_percentile": 147.98, "90th_percentile": 147.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 172.64, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 172.64, "10th_percentile": 172.64, "90th_percentile": 172.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 187.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.78, "10th_percentile": 187.78, "90th_percentile": 187.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 187.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.78, "10th_percentile": 187.78, "90th_percentile": 187.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ASPARAGINASE ERWINIA-RYWN 10 MG/0.5 ML IM SOLN", "drug_information": { "unit": 0.5, "type": "ML" }, "code_information": [ { "code": "RX-230830", "type": "CDM" }, { "code": "J9021", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "68727-0900-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 3277.34, "maximum": 47497.75, "setting": "outpatient", "gross_charge": 47497.75, "discounted_cash": 33248.42, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "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": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5095.7, "10th_percentile": 5095.7, "90th_percentile": 5095.7, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47,497.75 @ 11.5% = $5,462.24 due to $0.00 Claim Price", "median_amount": 5462.24, "10th_percentile": 5462.24, "90th_percentile": 5462.24, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47,497.75 @ 11.5% = $5,462.24 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5272.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5272.25, "10th_percentile": 5272.25, "90th_percentile": 5272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5272.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5272.25, "10th_percentile": 5272.25, "90th_percentile": 5272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5272.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5272.25, "10th_percentile": 5272.25, "90th_percentile": 5272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5272.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5272.25, "10th_percentile": 5272.25, "90th_percentile": 5272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5272.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5272.25, "10th_percentile": 5272.25, "90th_percentile": 5272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5272.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 5272.25, "10th_percentile": 5272.25, "90th_percentile": 5272.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 28498.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 28498.65, "10th_percentile": 28498.65, "90th_percentile": 28498.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 47497.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47,497.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47,497.75 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 47497.75, "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 $47,497.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "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 $47,497.75 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": "CDH BCBS HMO", "standard_charge_dollar": 19512.08, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19512.08, "10th_percentile": 19512.08, "90th_percentile": 19512.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 19512.08, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19512.08, "10th_percentile": 19512.08, "90th_percentile": 19512.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8359.6, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8359.6, "10th_percentile": 8359.6, "90th_percentile": 8359.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8359.6, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8359.6, "10th_percentile": 8359.6, "90th_percentile": 8359.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 6792.18, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 6792.18, "10th_percentile": 6792.18, "90th_percentile": 6792.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 16624.21, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 16624.21, "10th_percentile": 16624.21, "90th_percentile": 16624.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 14249.33, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 14249.33, "10th_percentile": 14249.33, "90th_percentile": 14249.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 14914.29, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 14914.29, "10th_percentile": 14914.29, "90th_percentile": 14914.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 5095.7, "10th_percentile": 5095.7, "90th_percentile": 5095.7, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47,497.75 @ 11.5% = $5,462.24 due to $0.00 Claim Price", "median_amount": 5462.24, "10th_percentile": 5462.24, "90th_percentile": 5462.24, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $47,497.75 @ 11.5% = $5,462.24 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 47497.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 47497.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 47497.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 47497.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47,497.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $47,497.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 47497.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 47497.75, "10th_percentile": 47497.75, "90th_percentile": 47497.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 28498.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 28498.65, "10th_percentile": 28498.65, "90th_percentile": 28498.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 28498.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 28498.65, "10th_percentile": 28498.65, "90th_percentile": 28498.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3277.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3277.34, "10th_percentile": 3277.34, "90th_percentile": 3277.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3277.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3277.34, "10th_percentile": 3277.34, "90th_percentile": 3277.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 3277.34, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3277.34, "10th_percentile": 3277.34, "90th_percentile": 3277.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 37998.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 37998.2, "10th_percentile": 37998.2, "90th_percentile": 37998.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 27263.71, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 27263.71, "10th_percentile": 27263.71, "90th_percentile": 27263.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 28498.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 28498.65, "10th_percentile": 28498.65, "90th_percentile": 28498.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 36525.77, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 36525.77, "10th_percentile": 36525.77, "90th_percentile": 36525.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 23748.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23748.88, "10th_percentile": 23748.88, "90th_percentile": 23748.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 41323.04, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 41323.04, "10th_percentile": 41323.04, "90th_percentile": 41323.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 36383.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 36383.28, "10th_percentile": 36383.28, "90th_percentile": 36383.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 43317.95, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 43317.95, "10th_percentile": 43317.95, "90th_percentile": 43317.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 29923.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 29923.58, "10th_percentile": 29923.58, "90th_percentile": 29923.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 23748.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 23748.88, "10th_percentile": 23748.88, "90th_percentile": 23748.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 37998.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 37998.2, "10th_percentile": 37998.2, "90th_percentile": 37998.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 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": "60687-0605-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.62, "maximum": 9.0, "setting": "outpatient", "gross_charge": 9.0, "discounted_cash": 6.3, "payers_information": [ { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4.75, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2.7, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 5.18, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2.83, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.29, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1.29, "10th_percentile": 1.29, "90th_percentile": 1.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 3.15, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 3.15, "10th_percentile": 3.15, "90th_percentile": 3.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.7, "10th_percentile": 3.7, "90th_percentile": 3.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.7, "10th_percentile": 3.7, "90th_percentile": 3.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.8, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1.58, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1.58, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.62, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price", "median_amount": 1.04, "10th_percentile": 1.04, "90th_percentile": 1.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 6.02, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.02, "10th_percentile": 6.02, "90th_percentile": 6.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4.52, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.52, "10th_percentile": 4.52, "90th_percentile": 4.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6.89, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6.89, "10th_percentile": 6.89, "90th_percentile": 6.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5.78, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5.78, "10th_percentile": 5.78, "90th_percentile": 5.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6.92, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 5.17, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5.67, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5.67, "10th_percentile": 5.67, "90th_percentile": 5.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 8.21, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 8.21, "10th_percentile": 8.21, "90th_percentile": 8.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7.83, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7.83, "10th_percentile": 7.83, "90th_percentile": 7.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.8, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.62, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.62, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price", "median_amount": 1.04, "10th_percentile": 1.04, "90th_percentile": 1.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price" } ] } ] }, { "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": 0.62, "maximum": 9.0, "setting": "outpatient", "gross_charge": 9.0, "discounted_cash": 6.3, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 6.02, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.02, "10th_percentile": 6.02, "90th_percentile": 6.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4.52, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.52, "10th_percentile": 4.52, "90th_percentile": 4.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6.89, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6.89, "10th_percentile": 6.89, "90th_percentile": 6.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5.78, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5.78, "10th_percentile": 5.78, "90th_percentile": 5.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6.92, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 5.17, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5.67, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5.67, "10th_percentile": 5.67, "90th_percentile": 5.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 8.21, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 8.21, "10th_percentile": 8.21, "90th_percentile": 8.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7.83, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7.83, "10th_percentile": 7.83, "90th_percentile": 7.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.7, "10th_percentile": 3.7, "90th_percentile": 3.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.7, "10th_percentile": 3.7, "90th_percentile": 3.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1.58, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1.58, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.8, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.8, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.29, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1.29, "10th_percentile": 1.29, "90th_percentile": 1.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 3.15, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 3.15, "10th_percentile": 3.15, "90th_percentile": 3.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2.7, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 5.18, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2.83, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4.75, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.62, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.62, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.62, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price", "median_amount": 1.04, "10th_percentile": 1.04, "90th_percentile": 1.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price", "median_amount": 1.04, "10th_percentile": 1.04, "90th_percentile": 1.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $9.00 @ 11.5% = $1.04 due to $0.00 Claim Price" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 4790.38, "maximum": 11191.95, "setting": "inpatient", "gross_charge": 44845.24, "discounted_cash": 31391.67, "payers_information": [ { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 26907.15, "10th_percentile": 26907.15, "90th_percentile": 26907.15, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 26907.15, "10th_percentile": 26907.15, "90th_percentile": 26907.15, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 26907.15, "10th_percentile": 26907.15, "90th_percentile": 26907.15, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; IP Services; 92% Billed", "median_amount": 41257.63, "10th_percentile": 41257.63, "90th_percentile": 41257.63, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; 92% Billed", "median_amount": 41257.63, "10th_percentile": 41257.63, "90th_percentile": 41257.63, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 22422.63, "10th_percentile": 22422.63, "90th_percentile": 22422.63, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 22422.63, "10th_percentile": 22422.63, "90th_percentile": 22422.63, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All Inpatient Services; 75.1% Billed", "median_amount": 33678.78, "10th_percentile": 33678.78, "90th_percentile": 33678.78, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient Services; 63% Billed", "median_amount": 28252.51, "10th_percentile": 28252.51, "90th_percentile": 28252.51, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 35876.2, "10th_percentile": 35876.2, "90th_percentile": 35876.2, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13005.12, "10th_percentile": 13005.12, "90th_percentile": 13005.12, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 39015.37, "10th_percentile": 39015.37, "90th_percentile": 39015.37, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 26189.62, "10th_percentile": 26189.62, "90th_percentile": 26189.62, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 6412.88, "10th_percentile": 6412.88, "90th_percentile": 6412.88, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All Inpatient Services; 37% Billed", "median_amount": 16592.74, "10th_percentile": 16592.74, "90th_percentile": 16592.74, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; 30% Billed", "median_amount": 13453.58, "10th_percentile": 13453.58, "90th_percentile": 13453.58, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All Inpatient Services; 32.6% Billed", "median_amount": 14619.55, "10th_percentile": 14619.55, "90th_percentile": 14619.55, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services - OON; 100% Billed", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; 100% Billed", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 44845.25, "10th_percentile": 44845.25, "90th_percentile": 44845.25, "count": "14", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8441.93, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 8441.93, "10th_percentile": 8441.93, "90th_percentile": 8441.93, "count": "14", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9201.97, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9201.97, "10th_percentile": 9201.97, "90th_percentile": 9201.97, "count": "14", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8948.85, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 8948.85, "10th_percentile": 8948.85, "90th_percentile": 8948.85, "count": "14", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 11191.95, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 11191.95, "10th_percentile": 11191.95, "90th_percentile": 11191.95, "count": "14", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 7125.82, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 7125.82, "10th_percentile": 7125.82, "90th_percentile": 7125.82, "count": "14", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8948.85, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 8948.85, "10th_percentile": 8948.85, "90th_percentile": 8948.85, "count": "14", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9201.97, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9201.97, "10th_percentile": 9201.97, "90th_percentile": 9201.97, "count": "14", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 11191.95, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 11191.95, "10th_percentile": 11191.95, "90th_percentile": 11191.95, "count": "14", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8441.93, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 8441.93, "10th_percentile": 8441.93, "90th_percentile": 8441.93, "count": "14", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 7125.82, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 7125.82, "10th_percentile": 7125.82, "90th_percentile": 7125.82, "count": "14", "methodology": "case rate" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $6,770.59; Percentage applied: 97.00%; Total: $6,567.47 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6567.47, "10th_percentile": 6567.47, "90th_percentile": 6567.47, "count": "14", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $6,770.59; Percentage applied: 97.00%; Total: $6,567.47 Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; 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: $5,151.38; Total: $5,151.38 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5151.38, "10th_percentile": 5151.38, "90th_percentile": 5151.38, "count": "14", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; 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: $5,151.38; Total: $5,151.38 Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $6,770.59; Total: $6,770.59", "median_amount": 6770.59, "10th_percentile": 6770.59, "90th_percentile": 6770.59, "count": "14", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $6,770.59; Total: $6,770.59" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $6,770.59; Total: $6,770.59", "median_amount": 6770.59, "10th_percentile": 6770.59, "90th_percentile": 6770.59, "count": "14", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.780632752; Using historical claim(s); Scope: All Financial Classes; Cases: 14; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $6,770.59; Total: $6,770.59" } ] } ] }, { "description": "ATOMOXETINE 40 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-34447", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0326-95", "type": "NDC" } ], "standard_charges": [ { "minimum": 25.2, "maximum": 176.25, "setting": "outpatient", "gross_charge": 176.25, "discounted_cash": 123.37, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 79.07, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.07, "10th_percentile": 79.07, "90th_percentile": 79.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 72.32, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.32, "10th_percentile": 72.32, "90th_percentile": 72.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 105.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 105.75, "10th_percentile": 105.75, "90th_percentile": 105.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 72.4, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.4, "10th_percentile": 72.4, "90th_percentile": 72.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 35.25, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 176.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $176.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $176.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 176.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $176.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $176.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 176.25, "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 $176.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "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 $176.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 176.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 37.72, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.72, "10th_percentile": 37.72, "90th_percentile": 37.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 72.32, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.32, "10th_percentile": 72.32, "90th_percentile": 72.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 117.91, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.91, "10th_percentile": 117.91, "90th_percentile": 117.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 79.07, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.07, "10th_percentile": 79.07, "90th_percentile": 79.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 101.17, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 101.17, "10th_percentile": 101.17, "90th_percentile": 101.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 141.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 141.0, "10th_percentile": 141.0, "90th_percentile": 141.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 88.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.13, "10th_percentile": 88.13, "90th_percentile": 88.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 72.79, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.79, "10th_percentile": 72.79, "90th_percentile": 72.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 88.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 88.13, "10th_percentile": 88.13, "90th_percentile": 88.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 105.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 105.75, "10th_percentile": 105.75, "90th_percentile": 105.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 135.01, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 135.01, "10th_percentile": 135.01, "90th_percentile": 135.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 141.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 141.0, "10th_percentile": 141.0, "90th_percentile": 141.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 153.34, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 153.34, "10th_percentile": 153.34, "90th_percentile": 153.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 35.25, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 35.25, "10th_percentile": 35.25, "90th_percentile": 35.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 72.4, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.4, "10th_percentile": 72.4, "90th_percentile": 72.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 113.21, "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": 113.21, "10th_percentile": 113.21, "90th_percentile": 113.21, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 160.74, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 160.74, "10th_percentile": 160.74, "90th_percentile": 160.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 135.54, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 135.54, "10th_percentile": 135.54, "90th_percentile": 135.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 88.48, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.48, "10th_percentile": 88.48, "90th_percentile": 88.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 111.04, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 111.04, "10th_percentile": 111.04, "90th_percentile": 111.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 176.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 176.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 176.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 25.2, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 25.2, "10th_percentile": 25.2, "90th_percentile": 25.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 55.34, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 55.34, "10th_percentile": 55.34, "90th_percentile": 55.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 93.06, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.06, "10th_percentile": 93.06, "90th_percentile": 93.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 101.52, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.52, "10th_percentile": 101.52, "90th_percentile": 101.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 52.88, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 52.88, "10th_percentile": 52.88, "90th_percentile": 52.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 61.69, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 61.69, "10th_percentile": 61.69, "90th_percentile": 61.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 105.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 105.75, "10th_percentile": 105.75, "90th_percentile": 105.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 105.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 105.75, "10th_percentile": 105.75, "90th_percentile": 105.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 67.1, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.1, "10th_percentile": 67.1, "90th_percentile": 67.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 67.1, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.1, "10th_percentile": 67.1, "90th_percentile": 67.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 67.1, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.1, "10th_percentile": 67.1, "90th_percentile": 67.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 67.1, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.1, "10th_percentile": 67.1, "90th_percentile": 67.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 176.25, "10th_percentile": 176.25, "90th_percentile": 176.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ATOVAQUONE-PROGUANIL 62.5-25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-84021", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "68462-0402-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 15.02, "maximum": 105.0, "setting": "outpatient", "gross_charge": 105.0, "discounted_cash": 73.5, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.97, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.97, "10th_percentile": 39.97, "90th_percentile": 39.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.97, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.97, "10th_percentile": 39.97, "90th_percentile": 39.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 39.97, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.97, "10th_percentile": 39.97, "90th_percentile": 39.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 39.97, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.97, "10th_percentile": 39.97, "90th_percentile": 39.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 63.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 63.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 63.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 60.27, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 60.27, "10th_percentile": 60.27, "90th_percentile": 60.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 52.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 52.5, "10th_percentile": 52.5, "90th_percentile": 52.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 95.76, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 95.76, "10th_percentile": 95.76, "90th_percentile": 95.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 52.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.5, "10th_percentile": 52.5, "90th_percentile": 52.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 91.35, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 91.35, "10th_percentile": 91.35, "90th_percentile": 91.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 80.75, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% 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 Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 22.47, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.47, "10th_percentile": 22.47, "90th_percentile": 22.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 84.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 84.0, "10th_percentile": 84.0, "90th_percentile": 84.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 66.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 66.15, "10th_percentile": 66.15, "90th_percentile": 66.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 80.43, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 80.43, "10th_percentile": 80.43, "90th_percentile": 80.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 67.44, "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": 67.44, "10th_percentile": 67.44, "90th_percentile": 67.44, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 63.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 63.0, "10th_percentile": 63.0, "90th_percentile": 63.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 43.37, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.37, "10th_percentile": 43.37, "90th_percentile": 43.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 70.25, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.25, "10th_percentile": 70.25, "90th_percentile": 70.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 84.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 84.0, "10th_percentile": 84.0, "90th_percentile": 84.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 52.71, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.71, "10th_percentile": 52.71, "90th_percentile": 52.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 21.0, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 21.0, "10th_percentile": 21.0, "90th_percentile": 21.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 21.0, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 21.0, "10th_percentile": 21.0, "90th_percentile": 21.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 36.75, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 36.75, "10th_percentile": 36.75, "90th_percentile": 36.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 15.02, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 15.02, "10th_percentile": 15.02, "90th_percentile": 15.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 43.08, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 43.08, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 43.13, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.13, "10th_percentile": 43.13, "90th_percentile": 43.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 43.13, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.13, "10th_percentile": 43.13, "90th_percentile": 43.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 47.1, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.1, "10th_percentile": 47.1, "90th_percentile": 47.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 47.1, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.1, "10th_percentile": 47.1, "90th_percentile": 47.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 105.0, "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 $105.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "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 $105.00 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $105.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $105.00 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $105.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $105.00 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 105.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 32.97, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 32.97, "10th_percentile": 32.97, "90th_percentile": 32.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 55.44, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.44, "10th_percentile": 55.44, "90th_percentile": 55.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 60.48, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.48, "10th_percentile": 60.48, "90th_percentile": 60.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 31.5, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 31.5, "10th_percentile": 31.5, "90th_percentile": 31.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% 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": 26.94, "maximum": 390.5, "setting": "outpatient", "gross_charge": 390.5, "discounted_cash": 273.35, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 7.6, "10th_percentile": 7.6, "90th_percentile": 7.6, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 7.6, "10th_percentile": 7.6, "90th_percentile": 7.6, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $390.50 @ 11.5% = $44.91 due to $0.00 Claim Price", "median_amount": 44.91, "10th_percentile": 44.91, "90th_percentile": 44.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $390.50 @ 11.5% = $44.91 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $390.50 @ 11.5% = $44.91 due to $0.00 Claim Price", "median_amount": 44.91, "10th_percentile": 44.91, "90th_percentile": 44.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $390.50 @ 11.5% = $44.91 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 43.35, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.35, "10th_percentile": 43.35, "90th_percentile": 43.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 43.35, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.35, "10th_percentile": 43.35, "90th_percentile": 43.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 43.35, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.35, "10th_percentile": 43.35, "90th_percentile": 43.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 43.35, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.35, "10th_percentile": 43.35, "90th_percentile": 43.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 43.35, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.35, "10th_percentile": 43.35, "90th_percentile": 43.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 43.35, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.35, "10th_percentile": 43.35, "90th_percentile": 43.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 234.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 234.3, "10th_percentile": 234.3, "90th_percentile": 234.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 234.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 234.3, "10th_percentile": 234.3, "90th_percentile": 234.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 234.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 234.3, "10th_percentile": 234.3, "90th_percentile": 234.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 26.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.94, "10th_percentile": 26.94, "90th_percentile": 26.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 26.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.94, "10th_percentile": 26.94, "90th_percentile": 26.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 26.94, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.94, "10th_percentile": 26.94, "90th_percentile": 26.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 390.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 390.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 390.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 390.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $390.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $390.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 390.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $390.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $390.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 390.5, "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 $390.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "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 $390.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 390.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 390.5, "10th_percentile": 390.5, "90th_percentile": 390.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 160.42, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.42, "10th_percentile": 160.42, "90th_percentile": 160.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 160.42, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.42, "10th_percentile": 160.42, "90th_percentile": 160.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 68.73, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.73, "10th_percentile": 68.73, "90th_percentile": 68.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 68.73, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.73, "10th_percentile": 68.73, "90th_percentile": 68.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 55.84, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 55.84, "10th_percentile": 55.84, "90th_percentile": 55.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 136.68, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 136.68, "10th_percentile": 136.68, "90th_percentile": 136.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 117.15, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 117.15, "10th_percentile": 117.15, "90th_percentile": 117.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 122.62, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 122.62, "10th_percentile": 122.62, "90th_percentile": 122.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 234.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 234.3, "10th_percentile": 234.3, "90th_percentile": 234.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 195.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.25, "10th_percentile": 195.25, "90th_percentile": 195.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 300.29, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 300.29, "10th_percentile": 300.29, "90th_percentile": 300.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 224.15, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 224.15, "10th_percentile": 224.15, "90th_percentile": 224.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 299.12, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 299.12, "10th_percentile": 299.12, "90th_percentile": 299.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 195.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 195.25, "10th_percentile": 195.25, "90th_percentile": 195.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 356.14, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 356.14, "10th_percentile": 356.14, "90th_percentile": 356.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 339.74, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 339.74, "10th_percentile": 339.74, "90th_percentile": 339.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 312.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 312.4, "10th_percentile": 312.4, "90th_percentile": 312.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 246.02, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 246.02, "10th_percentile": 246.02, "90th_percentile": 246.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 312.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 312.4, "10th_percentile": 312.4, "90th_percentile": 312.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "description": "ATROPINE 1 % OPHT DROP", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-736", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60219-1748-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 103.07, "maximum": 720.75, "setting": "outpatient", "gross_charge": 720.75, "discounted_cash": 504.52, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 295.72, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.72, "10th_percentile": 295.72, "90th_percentile": 295.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 296.08, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 296.08, "10th_percentile": 296.08, "90th_percentile": 296.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 323.33, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 323.33, "10th_percentile": 323.33, "90th_percentile": 323.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 360.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.38, "10th_percentile": 360.38, "90th_percentile": 360.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 552.09, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 552.09, "10th_percentile": 552.09, "90th_percentile": 552.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 154.24, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 154.24, "10th_percentile": 154.24, "90th_percentile": 154.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 576.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 576.6, "10th_percentile": 576.6, "90th_percentile": 576.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 297.67, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 297.67, "10th_percentile": 297.67, "90th_percentile": 297.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 576.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 576.6, "10th_percentile": 576.6, "90th_percentile": 576.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 554.26, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 554.26, "10th_percentile": 554.26, "90th_percentile": 554.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 657.32, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 657.32, "10th_percentile": 657.32, "90th_percentile": 657.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 360.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 360.38, "10th_percentile": 360.38, "90th_percentile": 360.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 252.26, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 252.26, "10th_percentile": 252.26, "90th_percentile": 252.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 216.23, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 216.23, "10th_percentile": 216.23, "90th_percentile": 216.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 415.15, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 415.15, "10th_percentile": 415.15, "90th_percentile": 415.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 226.32, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 226.32, "10th_percentile": 226.32, "90th_percentile": 226.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 380.56, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.56, "10th_percentile": 380.56, "90th_percentile": 380.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 103.07, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 103.07, "10th_percentile": 103.07, "90th_percentile": 103.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 274.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.39, "10th_percentile": 274.39, "90th_percentile": 274.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 274.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.39, "10th_percentile": 274.39, "90th_percentile": 274.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 432.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 432.45, "10th_percentile": 432.45, "90th_percentile": 432.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 323.33, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 323.33, "10th_percentile": 323.33, "90th_percentile": 323.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 432.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 432.45, "10th_percentile": 432.45, "90th_percentile": 432.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 144.15, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 144.15, "10th_percentile": 144.15, "90th_percentile": 144.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 296.08, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 296.08, "10th_percentile": 296.08, "90th_percentile": 296.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 295.72, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.72, "10th_percentile": 295.72, "90th_percentile": 295.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 720.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $720.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $720.75 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 720.75, "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 $720.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "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 $720.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 720.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $720.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $720.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 720.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 274.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.39, "10th_percentile": 274.39, "90th_percentile": 274.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 274.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.39, "10th_percentile": 274.39, "90th_percentile": 274.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 462.94, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 462.94, "10th_percentile": 462.94, "90th_percentile": 462.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 413.71, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 413.71, "10th_percentile": 413.71, "90th_percentile": 413.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 627.05, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 627.05, "10th_percentile": 627.05, "90th_percentile": 627.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 432.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 432.45, "10th_percentile": 432.45, "90th_percentile": 432.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 454.07, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 454.07, "10th_percentile": 454.07, "90th_percentile": 454.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 482.18, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 482.18, "10th_percentile": 482.18, "90th_percentile": 482.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 361.82, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 361.82, "10th_percentile": 361.82, "90th_percentile": 361.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 144.15, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 144.15, "10th_percentile": 144.15, "90th_percentile": 144.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 720.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 720.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 720.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 432.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 432.45, "10th_percentile": 432.45, "90th_percentile": 432.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 720.75, "10th_percentile": 720.75, "90th_percentile": 720.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ATROPINE 1 % OPHT DROP", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-736", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60505-6226-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 138.46, "maximum": 968.25, "setting": "outpatient", "gross_charge": 968.25, "discounted_cash": 677.77, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 368.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.61, "10th_percentile": 368.61, "90th_percentile": 368.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 368.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.61, "10th_percentile": 368.61, "90th_percentile": 368.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 368.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.61, "10th_percentile": 368.61, "90th_percentile": 368.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 368.61, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 368.61, "10th_percentile": 368.61, "90th_percentile": 368.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 580.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 580.95, "10th_percentile": 580.95, "90th_percentile": 580.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 580.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 580.95, "10th_percentile": 580.95, "90th_percentile": 580.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 580.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 580.95, "10th_percentile": 580.95, "90th_percentile": 580.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 397.76, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 397.76, "10th_percentile": 397.76, "90th_percentile": 397.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 397.76, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 397.76, "10th_percentile": 397.76, "90th_percentile": 397.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 968.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 968.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 968.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 968.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $968.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $968.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 968.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $968.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $968.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 968.25, "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 $968.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "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 $968.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 968.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 434.36, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 434.36, "10th_percentile": 434.36, "90th_percentile": 434.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 434.36, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 434.36, "10th_percentile": 434.36, "90th_percentile": 434.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 193.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 193.65, "10th_percentile": 193.65, "90th_percentile": 193.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 193.65, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 193.65, "10th_percentile": 193.65, "90th_percentile": 193.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 397.27, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 397.27, "10th_percentile": 397.27, "90th_percentile": 397.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 397.27, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 397.27, "10th_percentile": 397.27, "90th_percentile": 397.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 621.91, "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": 621.91, "10th_percentile": 621.91, "90th_percentile": 621.91, "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": "CDH HFN", "standard_charge_dollar": 883.04, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 883.04, "10th_percentile": 883.04, "90th_percentile": 883.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 744.58, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 744.58, "10th_percentile": 744.58, "90th_percentile": 744.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 580.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 580.95, "10th_percentile": 580.95, "90th_percentile": 580.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 610.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 610.0, "10th_percentile": 610.0, "90th_percentile": 610.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 774.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 774.6, "10th_percentile": 774.6, "90th_percentile": 774.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 207.21, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.21, "10th_percentile": 207.21, "90th_percentile": 207.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 741.68, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 741.68, "10th_percentile": 741.68, "90th_percentile": 741.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 484.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 484.13, "10th_percentile": 484.13, "90th_percentile": 484.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 774.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 774.6, "10th_percentile": 774.6, "90th_percentile": 774.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 842.38, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 842.38, "10th_percentile": 842.38, "90th_percentile": 842.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 647.76, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 647.76, "10th_percentile": 647.76, "90th_percentile": 647.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 399.89, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 399.89, "10th_percentile": 399.89, "90th_percentile": 399.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 486.06, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 486.06, "10th_percentile": 486.06, "90th_percentile": 486.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 555.78, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 555.78, "10th_percentile": 555.78, "90th_percentile": 555.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 484.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 484.13, "10th_percentile": 484.13, "90th_percentile": 484.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 557.71, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 557.71, "10th_percentile": 557.71, "90th_percentile": 557.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 290.48, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 290.48, "10th_percentile": 290.48, "90th_percentile": 290.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 338.89, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 338.89, "10th_percentile": 338.89, "90th_percentile": 338.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 138.46, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 138.46, "10th_percentile": 138.46, "90th_percentile": 138.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 968.25, "10th_percentile": 968.25, "90th_percentile": 968.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 511.24, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 511.24, "10th_percentile": 511.24, "90th_percentile": 511.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 304.03, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 304.03, "10th_percentile": 304.03, "90th_percentile": 304.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" } ] } ] }, { "description": "ATTACHMENT SWIVEL MAVERICK", "code_information": [ { "code": "SUP-447961", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1234.89, "maximum": 8635.61, "setting": "outpatient", "gross_charge": 8635.61, "discounted_cash": 6044.93, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3287.58, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3287.58, "10th_percentile": 3287.58, "90th_percentile": 3287.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3287.58, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3287.58, "10th_percentile": 3287.58, "90th_percentile": 3287.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3287.58, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3287.58, "10th_percentile": 3287.58, "90th_percentile": 3287.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3287.58, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3287.58, "10th_percentile": 3287.58, "90th_percentile": 3287.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5181.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5181.37, "10th_percentile": 5181.37, "90th_percentile": 5181.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5181.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5181.37, "10th_percentile": 5181.37, "90th_percentile": 5181.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,635.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,635.61 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,635.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,635.61 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,635.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,635.61 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2711.58, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2711.58, "10th_percentile": 2711.58, "90th_percentile": 2711.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 4974.11, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4974.11, "10th_percentile": 4974.11, "90th_percentile": 4974.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1234.89, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1234.89, "10th_percentile": 1234.89, "90th_percentile": 1234.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2590.68, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2590.68, "10th_percentile": 2590.68, "90th_percentile": 2590.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 3022.46, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 3022.46, "10th_percentile": 3022.46, "90th_percentile": 3022.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4559.6, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4559.6, "10th_percentile": 4559.6, "90th_percentile": 4559.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3543.19, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3543.19, "10th_percentile": 3543.19, "90th_percentile": 3543.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3543.19, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3543.19, "10th_percentile": 3543.19, "90th_percentile": 3543.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1727.12, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1727.12, "10th_percentile": 1727.12, "90th_percentile": 1727.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3547.51, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3547.51, "10th_percentile": 3547.51, "90th_percentile": 3547.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3547.51, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3547.51, "10th_percentile": 3547.51, "90th_percentile": 3547.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3873.93, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3873.93, "10th_percentile": 3873.93, "90th_percentile": 3873.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3873.93, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3873.93, "10th_percentile": 3873.93, "90th_percentile": 3873.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3566.51, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3566.51, "10th_percentile": 3566.51, "90th_percentile": 3566.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6908.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6908.49, "10th_percentile": 6908.49, "90th_percentile": 6908.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1848.02, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1848.02, "10th_percentile": 1848.02, "90th_percentile": 1848.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 6614.88, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6614.88, "10th_percentile": 6614.88, "90th_percentile": 6614.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 6908.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 6908.49, "10th_percentile": 6908.49, "90th_percentile": 6908.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4317.81, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4317.81, "10th_percentile": 4317.81, "90th_percentile": 4317.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8635.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4335.08, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4335.08, "10th_percentile": 4335.08, "90th_percentile": 4335.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6640.78, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6640.78, "10th_percentile": 6640.78, "90th_percentile": 6640.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5546.65, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5546.65, "10th_percentile": 5546.65, "90th_percentile": 5546.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH UHC HMO/PPO", "standard_charge_dollar": 5777.22, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5777.22, "10th_percentile": 5777.22, "90th_percentile": 5777.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 7875.68, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7875.68, "10th_percentile": 7875.68, "90th_percentile": 7875.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 4956.84, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 4956.84, "10th_percentile": 4956.84, "90th_percentile": 4956.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5181.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5181.37, "10th_percentile": 5181.37, "90th_percentile": 5181.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1727.12, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1727.12, "10th_percentile": 1727.12, "90th_percentile": 1727.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7512.98, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7512.98, "10th_percentile": 7512.98, "90th_percentile": 7512.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4317.81, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4317.81, "10th_percentile": 4317.81, "90th_percentile": 4317.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5440.43, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5440.43, "10th_percentile": 5440.43, "90th_percentile": 5440.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5181.37, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5181.37, "10th_percentile": 5181.37, "90th_percentile": 5181.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8635.61, "10th_percentile": 8635.61, "90th_percentile": 8635.61, "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": 165.13, "maximum": 2393.22, "setting": "outpatient", "gross_charge": 2393.22, "discounted_cash": 1675.25, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1601.06, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1677.12, "10th_percentile": 1677.12, "90th_percentile": 1677.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 988.4, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.27, "10th_percentile": 176.27, "90th_percentile": 176.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 478.64, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 35.37, "10th_percentile": 35.37, "90th_percentile": 35.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1914.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1914.58, "10th_percentile": 1914.58, "90th_percentile": 1914.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 2182.62, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2182.62, "10th_percentile": 2182.62, "90th_percentile": 2182.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 512.15, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 512.15, "10th_percentile": 512.15, "90th_percentile": 512.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 1537.17, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1537.17, "10th_percentile": 1537.17, "90th_percentile": 1537.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1435.93, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1435.93, "10th_percentile": 1435.93, "90th_percentile": 1435.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1914.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1914.58, "10th_percentile": 1914.58, "90th_percentile": 1914.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1840.39, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1840.39, "10th_percentile": 1840.39, "90th_percentile": 1840.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1373.71, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1373.71, "10th_percentile": 1373.71, "90th_percentile": 1373.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1201.4, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1201.4, "10th_percentile": 1201.4, "90th_percentile": 1201.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1507.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1507.73, "10th_percentile": 1507.73, "90th_percentile": 1507.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2082.1, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2082.1, "10th_percentile": 2082.1, "90th_percentile": 2082.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1196.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1196.61, "10th_percentile": 1196.61, "90th_percentile": 1196.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2393.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2393.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2393.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1435.93, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1435.93, "10th_percentile": 1435.93, "90th_percentile": 1435.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1435.93, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1435.93, "10th_percentile": 1435.93, "90th_percentile": 1435.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 165.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.13, "10th_percentile": 165.13, "90th_percentile": 165.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 165.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.13, "10th_percentile": 165.13, "90th_percentile": 165.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,393.22 @ 11.5% = $275.22 due to $0.00 Claim Price", "median_amount": 275.22, "10th_percentile": 275.22, "90th_percentile": 275.22, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,393.22 @ 11.5% = $275.22 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "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": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 478.64, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 35.37, "10th_percentile": 35.37, "90th_percentile": 35.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,393.22 @ 11.5% = $275.22 due to $0.00 Claim Price", "median_amount": 275.22, "10th_percentile": 275.22, "90th_percentile": 275.22, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,393.22 @ 11.5% = $275.22 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1196.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1196.61, "10th_percentile": 1196.61, "90th_percentile": 1196.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 1833.21, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1833.21, "10th_percentile": 1833.21, "90th_percentile": 1833.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 342.23, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 342.23, "10th_percentile": 342.23, "90th_percentile": 342.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 837.63, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 837.63, "10th_percentile": 837.63, "90th_percentile": 837.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 717.97, "10th_percentile": 717.97, "90th_percentile": 717.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1378.49, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1378.49, "10th_percentile": 1378.49, "90th_percentile": 1378.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1263.62, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1263.62, "10th_percentile": 1263.62, "90th_percentile": 1263.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 751.47, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 751.47, "10th_percentile": 751.47, "90th_percentile": 751.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 983.13, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 983.13, "10th_percentile": 983.13, "90th_percentile": 983.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 983.13, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 983.13, "10th_percentile": 983.13, "90th_percentile": 983.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 421.21, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.21, "10th_percentile": 421.21, "90th_percentile": 421.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 421.21, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.21, "10th_percentile": 421.21, "90th_percentile": 421.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1435.93, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1435.93, "10th_percentile": 1435.93, "90th_percentile": 1435.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2393.22, "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 $2,393.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "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 $2,393.22 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2393.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,393.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,393.22 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2393.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,393.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,393.22 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2393.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2393.22, "10th_percentile": 2393.22, "90th_percentile": 2393.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 165.13, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.13, "10th_percentile": 165.13, "90th_percentile": 165.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 265.65, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 265.65, "10th_percentile": 265.65, "90th_percentile": 265.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 265.65, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 265.65, "10th_percentile": 265.65, "90th_percentile": 265.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 265.65, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 265.65, "10th_percentile": 265.65, "90th_percentile": 265.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 265.65, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 265.65, "10th_percentile": 265.65, "90th_percentile": 265.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 265.65, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 265.65, "10th_percentile": 265.65, "90th_percentile": 265.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 265.65, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 265.65, "10th_percentile": 265.65, "90th_percentile": 265.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AUGMENT FEM 10MM SZ 9 DISTAL PSN REV 42556606610", "code_information": [ { "code": "SUP-345960", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 589.05, "maximum": 8536.92, "setting": "outpatient", "gross_charge": 8536.92, "discounted_cash": 5975.84, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1220.78, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 5711.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1826.9, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1826.9, "10th_percentile": 1826.9, "90th_percentile": 1826.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4285.53, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4285.53, "10th_percentile": 4285.53, "90th_percentile": 4285.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 5483.26, "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": 5483.26, "10th_percentile": 5483.26, "90th_percentile": 5483.26, "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": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 6829.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 6829.54, "10th_percentile": 6829.54, "90th_percentile": 6829.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7427.12, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7427.12, "10th_percentile": 7427.12, "90th_percentile": 7427.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4268.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4268.46, "10th_percentile": 4268.46, "90th_percentile": 4268.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 4900.19, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 4900.19, "10th_percentile": 4900.19, "90th_percentile": 4900.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6539.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6539.28, "10th_percentile": 6539.28, "90th_percentile": 6539.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 7785.67, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7785.67, "10th_percentile": 7785.67, "90th_percentile": 7785.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4268.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4268.46, "10th_percentile": 4268.46, "90th_percentile": 4268.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6829.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6829.54, "10th_percentile": 6829.54, "90th_percentile": 6829.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6564.89, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6564.89, "10th_percentile": 6564.89, "90th_percentile": 6564.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3525.75, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5378.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5378.26, "10th_percentile": 5378.26, "90th_percentile": 5378.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 4917.27, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4917.27, "10th_percentile": 4917.27, "90th_percentile": 4917.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4507.49, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4507.49, "10th_percentile": 4507.49, "90th_percentile": 4507.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2680.59, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2680.59, "10th_percentile": 2680.59, "90th_percentile": 2680.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2987.92, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2987.92, "10th_percentile": 2987.92, "90th_percentile": 2987.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2561.08, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2561.08, "10th_percentile": 2561.08, "90th_percentile": 2561.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1707.38, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1707.38, "10th_percentile": 1707.38, "90th_percentile": 1707.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1707.38, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1707.38, "10th_percentile": 1707.38, "90th_percentile": 1707.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1502.5, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1502.5, "10th_percentile": 1502.5, "90th_percentile": 1502.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1502.5, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1502.5, "10th_percentile": 1502.5, "90th_percentile": 1502.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3506.97, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3506.97, "10th_percentile": 3506.97, "90th_percentile": 3506.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3506.97, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3506.97, "10th_percentile": 3506.97, "90th_percentile": 3506.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price", "median_amount": 981.75, "10th_percentile": 981.75, "90th_percentile": 981.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price", "median_amount": 981.75, "10th_percentile": 981.75, "90th_percentile": 981.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AUGMENT FEM 10MM SZ11 DISTAL PERSONA", "code_information": [ { "code": "SUP-421168", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 589.05, "maximum": 8536.92, "setting": "outpatient", "gross_charge": 8536.92, "discounted_cash": 5975.84, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 5711.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 6829.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 6829.54, "10th_percentile": 6829.54, "90th_percentile": 6829.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4285.53, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4285.53, "10th_percentile": 4285.53, "90th_percentile": 4285.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4268.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4268.46, "10th_percentile": 4268.46, "90th_percentile": 4268.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5378.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5378.26, "10th_percentile": 5378.26, "90th_percentile": 5378.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4268.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4268.46, "10th_percentile": 4268.46, "90th_percentile": 4268.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 6539.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6539.28, "10th_percentile": 6539.28, "90th_percentile": 6539.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 4900.19, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 4900.19, "10th_percentile": 4900.19, "90th_percentile": 4900.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1826.9, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1826.9, "10th_percentile": 1826.9, "90th_percentile": 1826.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7427.12, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7427.12, "10th_percentile": 7427.12, "90th_percentile": 7427.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5483.26, "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": 5483.26, "10th_percentile": 5483.26, "90th_percentile": 5483.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6829.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6829.54, "10th_percentile": 6829.54, "90th_percentile": 6829.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 7785.67, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7785.67, "10th_percentile": 7785.67, "90th_percentile": 7785.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6564.89, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6564.89, "10th_percentile": 6564.89, "90th_percentile": 6564.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3525.75, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1707.38, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1707.38, "10th_percentile": 1707.38, "90th_percentile": 1707.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1707.38, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1707.38, "10th_percentile": 1707.38, "90th_percentile": 1707.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1502.5, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1502.5, "10th_percentile": 1502.5, "90th_percentile": 1502.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1502.5, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1502.5, "10th_percentile": 1502.5, "90th_percentile": 1502.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3506.97, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3506.97, "10th_percentile": 3506.97, "90th_percentile": 3506.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3506.97, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3506.97, "10th_percentile": 3506.97, "90th_percentile": 3506.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price", "median_amount": 981.75, "10th_percentile": 981.75, "90th_percentile": 981.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1220.78, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 4917.27, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4917.27, "10th_percentile": 4917.27, "90th_percentile": 4917.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4507.49, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4507.49, "10th_percentile": 4507.49, "90th_percentile": 4507.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2680.59, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2680.59, "10th_percentile": 2680.59, "90th_percentile": 2680.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2987.92, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2987.92, "10th_percentile": 2987.92, "90th_percentile": 2987.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2561.08, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2561.08, "10th_percentile": 2561.08, "90th_percentile": 2561.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price", "median_amount": 981.75, "10th_percentile": 981.75, "90th_percentile": 981.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price" } ] } ] }, { "description": "AUGMENT TIB 5MM SZEF RT MEDIAL HALF BLOCK PERSONA", "code_information": [ { "code": "SUP-352595", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 589.05, "maximum": 8536.92, "setting": "outpatient", "gross_charge": 8536.92, "discounted_cash": 5975.84, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1220.78, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price", "median_amount": 981.75, "10th_percentile": 981.75, "90th_percentile": 981.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 947.6, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 947.6, "10th_percentile": 947.6, "90th_percentile": 947.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6829.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 6829.54, "10th_percentile": 6829.54, "90th_percentile": 6829.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6539.28, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 6539.28, "10th_percentile": 6539.28, "90th_percentile": 6539.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4268.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4268.46, "10th_percentile": 4268.46, "90th_percentile": 4268.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3506.97, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3506.97, "10th_percentile": 3506.97, "90th_percentile": 3506.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1502.5, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1502.5, "10th_percentile": 1502.5, "90th_percentile": 1502.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1826.9, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1826.9, "10th_percentile": 1826.9, "90th_percentile": 1826.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 6829.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 6829.54, "10th_percentile": 6829.54, "90th_percentile": 6829.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3525.75, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2680.59, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 2680.59, "10th_percentile": 2680.59, "90th_percentile": 2680.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2987.92, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2987.92, "10th_percentile": 2987.92, "90th_percentile": 2987.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4507.49, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4507.49, "10th_percentile": 4507.49, "90th_percentile": 4507.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2561.08, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2561.08, "10th_percentile": 2561.08, "90th_percentile": 2561.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 4917.27, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4917.27, "10th_percentile": 4917.27, "90th_percentile": 4917.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1502.5, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1502.5, "10th_percentile": 1502.5, "90th_percentile": 1502.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1707.38, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1707.38, "10th_percentile": 1707.38, "90th_percentile": 1707.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3506.97, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3506.97, "10th_percentile": 3506.97, "90th_percentile": 3506.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,536.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 5711.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4285.53, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4285.53, "10th_percentile": 4285.53, "90th_percentile": 4285.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 5483.26, "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": 5483.26, "10th_percentile": 5483.26, "90th_percentile": 5483.26, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7427.12, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7427.12, "10th_percentile": 7427.12, "90th_percentile": 7427.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 4900.19, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 4900.19, "10th_percentile": 4900.19, "90th_percentile": 4900.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 7785.67, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7785.67, "10th_percentile": 7785.67, "90th_percentile": 7785.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4268.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4268.46, "10th_percentile": 4268.46, "90th_percentile": 4268.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6564.89, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6564.89, "10th_percentile": 6564.89, "90th_percentile": 6564.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5378.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5378.26, "10th_percentile": 5378.26, "90th_percentile": 5378.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1707.38, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1707.38, "10th_percentile": 1707.38, "90th_percentile": 1707.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8536.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 589.05, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 589.05, "10th_percentile": 589.05, "90th_percentile": 589.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5122.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 5122.15, "10th_percentile": 5122.15, "90th_percentile": 5122.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price", "median_amount": 981.75, "10th_percentile": 981.75, "90th_percentile": 981.75, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $8,536.92 @ 11.5% = $981.75 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8536.92, "10th_percentile": 8536.92, "90th_percentile": 8536.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AUGMENT TIB SM TRAB METAL CENTRAL REV PERSONA", "code_information": [ { "code": "SUP-374147", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 2343.16, "maximum": 33958.82, "setting": "outpatient", "gross_charge": 33958.82, "discounted_cash": 23771.17, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 4856.11, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $33,958.82 @ 11.5% = $3,905.26 due to $0.00 Claim Price", "median_amount": 3905.26, "10th_percentile": 3905.26, "90th_percentile": 3905.26, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $33,958.82 @ 11.5% = $3,905.26 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $33,958.82 @ 11.5% = $3,905.26 due to $0.00 Claim Price", "median_amount": 3905.26, "10th_percentile": 3905.26, "90th_percentile": 3905.26, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $33,958.82 @ 11.5% = $3,905.26 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3769.43, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3769.43, "10th_percentile": 3769.43, "90th_percentile": 3769.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3769.43, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3769.43, "10th_percentile": 3769.43, "90th_percentile": 3769.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3769.43, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3769.43, "10th_percentile": 3769.43, "90th_percentile": 3769.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3769.43, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3769.43, "10th_percentile": 3769.43, "90th_percentile": 3769.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3769.43, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3769.43, "10th_percentile": 3769.43, "90th_percentile": 3769.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3769.43, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3769.43, "10th_percentile": 3769.43, "90th_percentile": 3769.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2343.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2343.16, "10th_percentile": 2343.16, "90th_percentile": 2343.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2343.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2343.16, "10th_percentile": 2343.16, "90th_percentile": 2343.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2343.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2343.16, "10th_percentile": 2343.16, "90th_percentile": 2343.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 17047.33, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17047.33, "10th_percentile": 17047.33, "90th_percentile": 17047.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 27167.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 27167.06, "10th_percentile": 27167.06, "90th_percentile": 27167.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 29544.17, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 29544.17, "10th_percentile": 29544.17, "90th_percentile": 29544.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 21811.75, "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": 21811.75, "10th_percentile": 21811.75, "90th_percentile": 21811.75, "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": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 26012.46, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 26012.46, "10th_percentile": 26012.46, "90th_percentile": 26012.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 26114.33, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 26114.33, "10th_percentile": 26114.33, "90th_percentile": 26114.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 19492.36, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 19492.36, "10th_percentile": 19492.36, "90th_percentile": 19492.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 16979.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16979.41, "10th_percentile": 16979.41, "90th_percentile": 16979.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 30970.44, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 30970.44, "10th_percentile": 30970.44, "90th_percentile": 30970.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 20375.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 20375.29, "10th_percentile": 20375.29, "90th_percentile": 20375.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 21394.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 21394.06, "10th_percentile": 21394.06, "90th_percentile": 21394.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 13950.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13950.28, "10th_percentile": 13950.28, "90th_percentile": 13950.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5976.75, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5976.75, "10th_percentile": 5976.75, "90th_percentile": 5976.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 16979.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 16979.41, "10th_percentile": 16979.41, "90th_percentile": 16979.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 6791.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 6791.76, "10th_percentile": 6791.76, "90th_percentile": 6791.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 7267.19, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7267.19, "10th_percentile": 7267.19, "90th_percentile": 7267.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 27167.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 27167.06, "10th_percentile": 27167.06, "90th_percentile": 27167.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 22718.45, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 14024.99, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 10663.07, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 10663.07, "10th_percentile": 10663.07, "90th_percentile": 10663.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 11885.59, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 11885.59, "10th_percentile": 11885.59, "90th_percentile": 11885.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 17930.26, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17930.26, "10th_percentile": 17930.26, "90th_percentile": 17930.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 10187.65, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 10187.65, "10th_percentile": 10187.65, "90th_percentile": 10187.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 19560.28, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19560.28, "10th_percentile": 19560.28, "90th_percentile": 19560.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 20375.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 20375.29, "10th_percentile": 20375.29, "90th_percentile": 20375.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 20375.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 20375.29, "10th_percentile": 20375.29, "90th_percentile": 20375.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5976.75, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5976.75, "10th_percentile": 5976.75, "90th_percentile": 5976.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 6791.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 6791.76, "10th_percentile": 6791.76, "90th_percentile": 6791.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 13950.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13950.28, "10th_percentile": 13950.28, "90th_percentile": 13950.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 20375.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 20375.29, "10th_percentile": 20375.29, "90th_percentile": 20375.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $33,958.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $33,958.82 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $33,958.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $33,958.82 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 33958.82, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $33,958.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 33958.82, "10th_percentile": 33958.82, "90th_percentile": 33958.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $33,958.82 so that total pmt for all claim lines does not exceed 100% of claim billed amount." } ] } ] }, { "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": 1683.46, "maximum": 24397.98, "setting": "outpatient", "gross_charge": 24397.98, "discounted_cash": 17078.59, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3488.91, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1329.18, "10th_percentile": 1329.18, "90th_percentile": 1329.18, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2708.18, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2708.18, "10th_percentile": 2708.18, "90th_percentile": 2708.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2708.18, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2708.18, "10th_percentile": 2708.18, "90th_percentile": 2708.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2708.18, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2708.18, "10th_percentile": 2708.18, "90th_percentile": 2708.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2708.18, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2708.18, "10th_percentile": 2708.18, "90th_percentile": 2708.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2708.18, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2708.18, "10th_percentile": 2708.18, "90th_percentile": 2708.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2708.18, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2708.18, "10th_percentile": 2708.18, "90th_percentile": 2708.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14638.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14638.79, "10th_percentile": 14638.79, "90th_percentile": 14638.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14638.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14638.79, "10th_percentile": 14638.79, "90th_percentile": 14638.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14638.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14638.79, "10th_percentile": 14638.79, "90th_percentile": 14638.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "HMO PAY OBVS; 100% Billed", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "HMO PAY OBVS; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,397.98 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,397.98 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,397.98 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24,397.98 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 24397.98, "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 $24,397.98 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "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 $24,397.98 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 24397.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1683.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1683.46, "10th_percentile": 1683.46, "90th_percentile": 1683.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1683.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1683.46, "10th_percentile": 1683.46, "90th_percentile": 1683.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1683.46, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1683.46, "10th_percentile": 1683.46, "90th_percentile": 1683.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4294.04, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4294.04, "10th_percentile": 4294.04, "90th_percentile": 4294.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4294.04, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4294.04, "10th_percentile": 4294.04, "90th_percentile": 4294.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 10076.37, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10076.37, "10th_percentile": 10076.37, "90th_percentile": 10076.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 5221.17, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5221.17, "10th_percentile": 5221.17, "90th_percentile": 5221.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 16322.25, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16322.25, "10th_percentile": 16322.25, "90th_percentile": 16322.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 12247.79, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12247.79, "10th_percentile": 12247.79, "90th_percentile": 12247.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 18762.05, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 18762.05, "10th_percentile": 18762.05, "90th_percentile": 18762.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 19518.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 19518.38, "10th_percentile": 19518.38, "90th_percentile": 19518.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 22250.96, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 22250.96, "10th_percentile": 22250.96, "90th_percentile": 22250.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 14004.44, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 14004.44, "10th_percentile": 14004.44, "90th_percentile": 14004.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 12198.99, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 12198.99, "10th_percentile": 12198.99, "90th_percentile": 12198.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 12198.99, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12198.99, "10th_percentile": 12198.99, "90th_percentile": 12198.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 18688.85, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 18688.85, "10th_percentile": 18688.85, "90th_percentile": 18688.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 21226.24, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 21226.24, "10th_percentile": 21226.24, "90th_percentile": 21226.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 14638.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 14638.79, "10th_percentile": 14638.79, "90th_percentile": 14638.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 15370.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 15370.73, "10th_percentile": 15370.73, "90th_percentile": 15370.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 19518.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 19518.38, "10th_percentile": 19518.38, "90th_percentile": 19518.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 15670.82, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 15670.82, "10th_percentile": 15670.82, "90th_percentile": 15670.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10022.69, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10022.69, "10th_percentile": 10022.69, "90th_percentile": 10022.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10022.69, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10022.69, "10th_percentile": 10022.69, "90th_percentile": 10022.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 8539.29, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 8539.29, "10th_percentile": 8539.29, "90th_percentile": 8539.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,397.98 @ 11.5% = $2,805.77 due to $0.00 Claim Price", "median_amount": 2805.77, "10th_percentile": 2805.77, "90th_percentile": 2805.77, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,397.98 @ 11.5% = $2,805.77 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,397.98 @ 11.5% = $2,805.77 due to $0.00 Claim Price", "median_amount": 2805.77, "10th_percentile": 2805.77, "90th_percentile": 2805.77, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24,397.98 @ 11.5% = $2,805.77 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24397.98, "10th_percentile": 24397.98, "90th_percentile": 24397.98, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 7660.97, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 7660.97, "10th_percentile": 7660.97, "90th_percentile": 7660.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 14053.24, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14053.24, "10th_percentile": 14053.24, "90th_percentile": 14053.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 12882.13, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12882.13, "10th_percentile": 12882.13, "90th_percentile": 12882.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 7319.39, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 7319.39, "10th_percentile": 7319.39, "90th_percentile": 7319.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" } ] } ] }, { "description": "AXIEM TRACER POINTER / PROBE 9735428 (2 of 2 parts)", "code_information": [ { "code": "SUP-358865", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 867.52, "maximum": 6066.57, "setting": "outpatient", "gross_charge": 6066.57, "discounted_cash": 4246.6, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2309.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2309.54, "10th_percentile": 2309.54, "90th_percentile": 2309.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2309.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2309.54, "10th_percentile": 2309.54, "90th_percentile": 2309.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2309.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2309.54, "10th_percentile": 2309.54, "90th_percentile": 2309.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2309.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2309.54, "10th_percentile": 2309.54, "90th_percentile": 2309.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3639.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3639.94, "10th_percentile": 3639.94, "90th_percentile": 3639.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3639.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3639.94, "10th_percentile": 3639.94, "90th_percentile": 3639.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3639.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3639.94, "10th_percentile": 3639.94, "90th_percentile": 3639.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,066.57 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,066.57 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,066.57 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,066.57 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,066.57 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,066.57 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6066.57, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1904.9, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1904.9, "10th_percentile": 1904.9, "90th_percentile": 1904.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3494.34, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3494.34, "10th_percentile": 3494.34, "90th_percentile": 3494.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 867.52, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 867.52, "10th_percentile": 867.52, "90th_percentile": 867.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1819.97, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1819.97, "10th_percentile": 1819.97, "90th_percentile": 1819.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2123.3, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2123.3, "10th_percentile": 2123.3, "90th_percentile": 2123.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3203.15, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3203.15, "10th_percentile": 3203.15, "90th_percentile": 3203.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2489.11, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2489.11, "10th_percentile": 2489.11, "90th_percentile": 2489.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2489.11, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2489.11, "10th_percentile": 2489.11, "90th_percentile": 2489.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1213.31, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1213.31, "10th_percentile": 1213.31, "90th_percentile": 1213.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1213.31, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1213.31, "10th_percentile": 1213.31, "90th_percentile": 1213.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2492.15, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2492.15, "10th_percentile": 2492.15, "90th_percentile": 2492.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2492.15, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2492.15, "10th_percentile": 2492.15, "90th_percentile": 2492.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2721.46, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2721.46, "10th_percentile": 2721.46, "90th_percentile": 2721.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2721.46, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2721.46, "10th_percentile": 2721.46, "90th_percentile": 2721.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3639.94, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3639.94, "10th_percentile": 3639.94, "90th_percentile": 3639.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 4058.54, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4058.54, "10th_percentile": 4058.54, "90th_percentile": 4058.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 3045.42, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3045.42, "10th_percentile": 3045.42, "90th_percentile": 3045.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 5532.71, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 5532.71, "10th_percentile": 5532.71, "90th_percentile": 5532.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 3896.56, "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": 3896.56, "10th_percentile": 3896.56, "90th_percentile": 3896.56, "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": "CDH CIGNA BROAD", "standard_charge_dollar": 2505.49, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2505.49, "10th_percentile": 2505.49, "90th_percentile": 2505.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4853.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4853.26, "10th_percentile": 4853.26, "90th_percentile": 4853.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 3033.29, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 3033.29, "10th_percentile": 3033.29, "90th_percentile": 3033.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1298.25, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1298.25, "10th_percentile": 1298.25, "90th_percentile": 1298.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3482.21, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3482.21, "10th_percentile": 3482.21, "90th_percentile": 3482.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5277.92, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5277.92, "10th_percentile": 5277.92, "90th_percentile": 5277.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3821.94, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3821.94, "10th_percentile": 3821.94, "90th_percentile": 3821.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4665.19, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4665.19, "10th_percentile": 4665.19, "90th_percentile": 4665.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 4646.99, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 4646.99, "10th_percentile": 4646.99, "90th_percentile": 4646.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 4853.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 4853.26, "10th_percentile": 4853.26, "90th_percentile": 4853.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 3033.29, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3033.29, "10th_percentile": 3033.29, "90th_percentile": 3033.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6066.57, "10th_percentile": 6066.57, "90th_percentile": 6066.57, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AZITHROMYCIN 1 G ORAL PACK", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-15284", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "59762-3051-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 77.61, "maximum": 542.75, "setting": "outpatient", "gross_charge": 542.75, "discounted_cash": 379.92, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 206.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.62, "10th_percentile": 206.62, "90th_percentile": 206.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 206.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.62, "10th_percentile": 206.62, "90th_percentile": 206.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 206.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.62, "10th_percentile": 206.62, "90th_percentile": 206.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 206.62, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.62, "10th_percentile": 206.62, "90th_percentile": 206.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 325.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 325.65, "10th_percentile": 325.65, "90th_percentile": 325.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 271.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 271.38, "10th_percentile": 271.38, "90th_percentile": 271.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 116.15, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.15, "10th_percentile": 116.15, "90th_percentile": 116.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 415.75, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 415.75, "10th_percentile": 415.75, "90th_percentile": 415.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 108.55, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 108.55, "10th_percentile": 108.55, "90th_percentile": 108.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 312.62, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 312.62, "10th_percentile": 312.62, "90th_percentile": 312.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 170.42, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 170.42, "10th_percentile": 170.42, "90th_percentile": 170.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 286.57, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.57, "10th_percentile": 286.57, "90th_percentile": 286.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 189.96, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 189.96, "10th_percentile": 189.96, "90th_percentile": 189.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 77.61, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 77.61, "10th_percentile": 77.61, "90th_percentile": 77.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 162.83, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 162.83, "10th_percentile": 162.83, "90th_percentile": 162.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 222.69, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.69, "10th_percentile": 222.69, "90th_percentile": 222.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 222.69, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.69, "10th_percentile": 222.69, "90th_percentile": 222.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 222.96, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.96, "10th_percentile": 222.96, "90th_percentile": 222.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 222.96, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.96, "10th_percentile": 222.96, "90th_percentile": 222.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 243.48, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.48, "10th_percentile": 243.48, "90th_percentile": 243.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 243.48, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.48, "10th_percentile": 243.48, "90th_percentile": 243.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 542.75, "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 $542.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "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 $542.75 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 542.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $542.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $542.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 542.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $542.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $542.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 542.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 325.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 325.65, "10th_percentile": 325.65, "90th_percentile": 325.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 325.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 325.65, "10th_percentile": 325.65, "90th_percentile": 325.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 542.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 542.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 542.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 542.75, "10th_percentile": 542.75, "90th_percentile": 542.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 108.55, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 108.55, "10th_percentile": 108.55, "90th_percentile": 108.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 271.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 271.38, "10th_percentile": 271.38, "90th_percentile": 271.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 363.1, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.1, "10th_percentile": 363.1, "90th_percentile": 363.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 325.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 325.65, "10th_percentile": 325.65, "90th_percentile": 325.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 434.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 434.2, "10th_percentile": 434.2, "90th_percentile": 434.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 272.46, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.46, "10th_percentile": 272.46, "90th_percentile": 272.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 311.54, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 311.54, "10th_percentile": 311.54, "90th_percentile": 311.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 472.19, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 472.19, "10th_percentile": 472.19, "90th_percentile": 472.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 348.61, "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": 348.61, "10th_percentile": 348.61, "90th_percentile": 348.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 224.16, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 341.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 341.93, "10th_percentile": 341.93, "90th_percentile": 341.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 434.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 434.2, "10th_percentile": 434.2, "90th_percentile": 434.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 417.37, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 417.37, "10th_percentile": 417.37, "90th_percentile": 417.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 494.99, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 494.99, "10th_percentile": 494.99, "90th_percentile": 494.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" } ] } ] }, { "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": 3.7, "maximum": 25.86, "setting": "outpatient", "gross_charge": 25.86, "discounted_cash": 18.1, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10.62, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 11.6, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.61, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.61, "10th_percentile": 10.61, "90th_percentile": 10.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 7.76, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 7.76, "10th_percentile": 7.76, "90th_percentile": 7.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.7, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% 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 Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 13.65, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.65, "10th_percentile": 13.65, "90th_percentile": 13.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 8.12, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 8.12, "10th_percentile": 8.12, "90th_percentile": 8.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 9.05, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 9.05, "10th_percentile": 9.05, "90th_percentile": 9.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 14.9, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.9, "10th_percentile": 14.9, "90th_percentile": 14.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.61, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.61, "10th_percentile": 10.61, "90th_percentile": 10.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 15.52, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 15.52, "10th_percentile": 15.52, "90th_percentile": 15.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10.62, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 11.6, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 25.86, "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 $25.86 so that total pmt for all claim lines does not exceed 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": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.84, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.84, "10th_percentile": 9.84, "90th_percentile": 9.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.84, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.84, "10th_percentile": 9.84, "90th_percentile": 9.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.84, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.84, "10th_percentile": 9.84, "90th_percentile": 9.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.84, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.84, "10th_percentile": 9.84, "90th_percentile": 9.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 5.17, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 25.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.86 so that total pmt for all claim lines does not exceed 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": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.86 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 25.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.86 so that total pmt for all claim lines does not exceed 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": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.86 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 25.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 15.52, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 15.52, "10th_percentile": 15.52, "90th_percentile": 15.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 15.52, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 15.52, "10th_percentile": 15.52, "90th_percentile": 15.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 25.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 5.17, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 12.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.93, "10th_percentile": 12.93, "90th_percentile": 12.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 19.89, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 19.89, "10th_percentile": 19.89, "90th_percentile": 19.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 16.29, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 16.29, "10th_percentile": 16.29, "90th_percentile": 16.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 20.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 20.69, "10th_percentile": 20.69, "90th_percentile": 20.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 12.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 12.93, "10th_percentile": 12.93, "90th_percentile": 12.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 19.81, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 19.81, "10th_percentile": 19.81, "90th_percentile": 19.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 20.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 20.69, "10th_percentile": 20.69, "90th_percentile": 20.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 14.84, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 14.84, "10th_percentile": 14.84, "90th_percentile": 14.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 25.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 23.58, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 23.58, "10th_percentile": 23.58, "90th_percentile": 23.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.53, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.53, "10th_percentile": 5.53, "90th_percentile": 5.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 12.98, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.98, "10th_percentile": 12.98, "90th_percentile": 12.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 15.52, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 15.52, "10th_percentile": 15.52, "90th_percentile": 15.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 10.68, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.68, "10th_percentile": 10.68, "90th_percentile": 10.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 17.3, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.3, "10th_percentile": 17.3, "90th_percentile": 17.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 22.5, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 22.5, "10th_percentile": 22.5, "90th_percentile": 22.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 16.61, "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": 16.61, "10th_percentile": 16.61, "90th_percentile": 16.61, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 25.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "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": 70.18, "maximum": 1017.12, "setting": "outpatient", "gross_charge": 1017.12, "discounted_cash": 711.98, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 203.42, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 203.42, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price", "median_amount": 116.97, "10th_percentile": 116.97, "90th_percentile": 116.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price", "median_amount": 116.97, "10th_percentile": 116.97, "90th_percentile": 116.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 680.45, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 680.45, "10th_percentile": 680.45, "90th_percentile": 680.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 510.59, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.59, "10th_percentile": 510.59, "90th_percentile": 510.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 653.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 653.3, "10th_percentile": 653.3, "90th_percentile": 653.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 583.83, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 583.83, "10th_percentile": 583.83, "90th_percentile": 583.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 884.89, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 884.89, "10th_percentile": 884.89, "90th_percentile": 884.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 779.11, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 779.11, "10th_percentile": 779.11, "90th_percentile": 779.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 217.66, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 217.66, "10th_percentile": 217.66, "90th_percentile": 217.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 420.07, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 640.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 640.79, "10th_percentile": 640.79, "90th_percentile": 640.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 927.61, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 927.61, "10th_percentile": 927.61, "90th_percentile": 927.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 782.17, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 782.17, "10th_percentile": 782.17, "90th_percentile": 782.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 305.14, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 305.14, "10th_percentile": 305.14, "90th_percentile": 305.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 585.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 585.86, "10th_percentile": 585.86, "90th_percentile": 585.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 319.38, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 319.38, "10th_percentile": 319.38, "90th_percentile": 319.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 537.04, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 537.04, "10th_percentile": 537.04, "90th_percentile": 537.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 145.45, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 145.45, "10th_percentile": 145.45, "90th_percentile": 145.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 355.99, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 355.99, "10th_percentile": 355.99, "90th_percentile": 355.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 813.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 813.7, "10th_percentile": 813.7, "90th_percentile": 813.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 813.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 813.7, "10th_percentile": 813.7, "90th_percentile": 813.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 417.83, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.83, "10th_percentile": 417.83, "90th_percentile": 417.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 417.83, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.83, "10th_percentile": 417.83, "90th_percentile": 417.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 179.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.01, "10th_percentile": 179.01, "90th_percentile": 179.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 179.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.01, "10th_percentile": 179.01, "90th_percentile": 179.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 508.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 508.56, "10th_percentile": 508.56, "90th_percentile": 508.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 508.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 508.56, "10th_percentile": 508.56, "90th_percentile": 508.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1017.12, "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 $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "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 $1,017.12 so that total pmt for all claim lines does not exceed 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": 70.18, "maximum": 1017.12, "setting": "outpatient", "gross_charge": 1017.12, "discounted_cash": 711.98, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 203.42, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 927.61, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 927.61, "10th_percentile": 927.61, "90th_percentile": 927.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 640.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 640.79, "10th_percentile": 640.79, "90th_percentile": 640.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 782.17, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 782.17, "10th_percentile": 782.17, "90th_percentile": 782.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 510.59, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.59, "10th_percentile": 510.59, "90th_percentile": 510.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 583.83, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 583.83, "10th_percentile": 583.83, "90th_percentile": 583.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 680.45, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 680.45, "10th_percentile": 680.45, "90th_percentile": 680.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 884.89, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 884.89, "10th_percentile": 884.89, "90th_percentile": 884.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 653.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 653.3, "10th_percentile": 653.3, "90th_percentile": 653.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 508.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 508.56, "10th_percentile": 508.56, "90th_percentile": 508.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price", "median_amount": 116.97, "10th_percentile": 116.97, "90th_percentile": 116.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "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": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 203.42, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 420.07, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 217.66, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 217.66, "10th_percentile": 217.66, "90th_percentile": 217.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 779.11, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 779.11, "10th_percentile": 779.11, "90th_percentile": 779.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 145.45, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 145.45, "10th_percentile": 145.45, "90th_percentile": 145.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 355.99, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 355.99, "10th_percentile": 355.99, "90th_percentile": 355.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 319.38, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 319.38, "10th_percentile": 319.38, "90th_percentile": 319.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 537.04, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 537.04, "10th_percentile": 537.04, "90th_percentile": 537.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 305.14, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 305.14, "10th_percentile": 305.14, "90th_percentile": 305.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 585.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 585.86, "10th_percentile": 585.86, "90th_percentile": 585.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 813.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 813.7, "10th_percentile": 813.7, "90th_percentile": 813.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 813.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 813.7, "10th_percentile": 813.7, "90th_percentile": 813.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 179.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.01, "10th_percentile": 179.01, "90th_percentile": 179.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 179.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.01, "10th_percentile": 179.01, "90th_percentile": 179.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 508.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 508.56, "10th_percentile": 508.56, "90th_percentile": 508.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 417.83, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.83, "10th_percentile": 417.83, "90th_percentile": 417.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 417.83, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.83, "10th_percentile": 417.83, "90th_percentile": 417.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1017.12, "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 $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "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 $1,017.12 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price", "median_amount": 116.97, "10th_percentile": 116.97, "90th_percentile": 116.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 70.18, "maximum": 1017.12, "setting": "outpatient", "gross_charge": 1017.12, "discounted_cash": 711.98, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 203.42, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 203.42, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price", "median_amount": 116.97, "10th_percentile": 116.97, "90th_percentile": 116.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price", "median_amount": 116.97, "10th_percentile": 116.97, "90th_percentile": 116.97, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,017.12 @ 11.5% = $116.97 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 680.45, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 680.45, "10th_percentile": 680.45, "90th_percentile": 680.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 510.59, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.59, "10th_percentile": 510.59, "90th_percentile": 510.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 653.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 653.3, "10th_percentile": 653.3, "90th_percentile": 653.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 583.83, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 583.83, "10th_percentile": 583.83, "90th_percentile": 583.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 884.89, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 884.89, "10th_percentile": 884.89, "90th_percentile": 884.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 779.11, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 779.11, "10th_percentile": 779.11, "90th_percentile": 779.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 217.66, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 217.66, "10th_percentile": 217.66, "90th_percentile": 217.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 420.07, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 640.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 640.79, "10th_percentile": 640.79, "90th_percentile": 640.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 927.61, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 927.61, "10th_percentile": 927.61, "90th_percentile": 927.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 782.17, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 782.17, "10th_percentile": 782.17, "90th_percentile": 782.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 305.14, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 305.14, "10th_percentile": 305.14, "90th_percentile": 305.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 585.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 585.86, "10th_percentile": 585.86, "90th_percentile": 585.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 319.38, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 319.38, "10th_percentile": 319.38, "90th_percentile": 319.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 537.04, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 537.04, "10th_percentile": 537.04, "90th_percentile": 537.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 145.45, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 145.45, "10th_percentile": 145.45, "90th_percentile": 145.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 355.99, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 355.99, "10th_percentile": 355.99, "90th_percentile": 355.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 813.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 813.7, "10th_percentile": 813.7, "90th_percentile": 813.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 813.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 813.7, "10th_percentile": 813.7, "90th_percentile": 813.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 417.83, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.83, "10th_percentile": 417.83, "90th_percentile": 417.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 417.83, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.83, "10th_percentile": 417.83, "90th_percentile": 417.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 179.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.01, "10th_percentile": 179.01, "90th_percentile": 179.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 179.01, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 179.01, "10th_percentile": 179.01, "90th_percentile": 179.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 508.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 508.56, "10th_percentile": 508.56, "90th_percentile": 508.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 508.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 508.56, "10th_percentile": 508.56, "90th_percentile": 508.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 70.18, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.18, "10th_percentile": 70.18, "90th_percentile": 70.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 610.27, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 112.9, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 112.9, "10th_percentile": 112.9, "90th_percentile": 112.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1017.12, "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 $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "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 $1,017.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." } ] } ] }, { "description": "Arthroscopy Hip Surgical W/Synovectomy", "code_information": [ { "code": "CASE-29863", "type": "LOCAL" }, { "code": "29863", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132378.34, "discounted_cash": 92664.84, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_percentage": 41.08, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 4045.0, "10th_percentile": 4045.0, "90th_percentile": 4045.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_percentage": 41.08, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 4045.0, "10th_percentile": 4045.0, "90th_percentile": 4045.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_percentage": 39.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 52024.7, "10th_percentile": 52024.7, "90th_percentile": 52024.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 31.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41566.79, "10th_percentile": 41566.79, "90th_percentile": 41566.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_percentage": 42.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 56657.95, "10th_percentile": 56657.95, "90th_percentile": 56657.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 39713.57, "10th_percentile": 39713.57, "90th_percentile": 39713.57, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 35.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 46332.43, "10th_percentile": 46332.43, "90th_percentile": 46332.43, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 18930.09, "10th_percentile": 18930.09, "90th_percentile": 18930.09, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_percentage": 36.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 48450.51, "10th_percentile": 48450.51, "90th_percentile": 48450.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_percentage": 36.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 48450.51, "10th_percentile": 48450.51, "90th_percentile": 48450.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 9134.12, "10th_percentile": 9134.12, "90th_percentile": 9134.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 66189.24, "10th_percentile": 66189.24, "90th_percentile": 66189.24, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 101401.85, "10th_percentile": 101401.85, "90th_percentile": 101401.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_percentage": 21.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27318.3, "10th_percentile": 27318.3, "90th_percentile": 27318.3, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 105902.68, "10th_percentile": 105902.68, "90th_percentile": 105902.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_percentage": 41.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 52688.53, "10th_percentile": 52688.53, "90th_percentile": 52688.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 105902.68, "10th_percentile": 105902.68, "90th_percentile": 105902.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 9134.12, "10th_percentile": 9134.12, "90th_percentile": 9134.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 76.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 101798.93, "10th_percentile": 101798.93, "90th_percentile": 101798.93, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 9134.12, "10th_percentile": 9134.12, "90th_percentile": 9134.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 91.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 120729.05, "10th_percentile": 120729.05, "90th_percentile": 120729.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 66189.24, "10th_percentile": 66189.24, "90th_percentile": 66189.24, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 83398.37, "10th_percentile": 83398.37, "90th_percentile": 83398.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 115169.17, "10th_percentile": 115169.17, "90th_percentile": 115169.17, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 57.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 75985.18, "10th_percentile": 75985.18, "90th_percentile": 75985.18, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 83170.2, "10th_percentile": 83170.2, "90th_percentile": 83170.2, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 64045.67, "10th_percentile": 64045.67, "90th_percentile": 64045.67, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 85336.26, "10th_percentile": 85336.26, "90th_percentile": 85336.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132181.98, "10th_percentile": 132181.98, "90th_percentile": 132181.98, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132179.7, "10th_percentile": 132179.7, "90th_percentile": 132179.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_percentage": 93.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 4; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price" } ] } ] }, { "description": "Arthroscopy Hip W/Femoroplasty", "code_information": [ { "code": "CASE-29914", "type": "LOCAL" }, { "code": "29914", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132378.34, "discounted_cash": 92664.84, "payers_information": [ { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132181.98, "10th_percentile": 132181.98, "90th_percentile": 132181.98, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132378.34, "10th_percentile": 132378.34, "90th_percentile": 132378.34, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 132179.7, "10th_percentile": 132179.7, "90th_percentile": 132179.7, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 105902.68, "10th_percentile": 105902.68, "90th_percentile": 105902.68, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 9134.12, "10th_percentile": 9134.12, "90th_percentile": 9134.12, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 76.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 101798.93, "10th_percentile": 101798.93, "90th_percentile": 101798.93, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 9134.12, "10th_percentile": 9134.12, "90th_percentile": 9134.12, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 91.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 120729.05, "10th_percentile": 120729.05, "90th_percentile": 120729.05, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 66189.24, "10th_percentile": 66189.24, "90th_percentile": 66189.24, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 83398.37, "10th_percentile": 83398.37, "90th_percentile": 83398.37, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 115169.17, "10th_percentile": 115169.17, "90th_percentile": 115169.17, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 57.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 75985.18, "10th_percentile": 75985.18, "90th_percentile": 75985.18, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 83170.2, "10th_percentile": 83170.2, "90th_percentile": 83170.2, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 64045.67, "10th_percentile": 64045.67, "90th_percentile": 64045.67, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 85336.26, "10th_percentile": 85336.26, "90th_percentile": 85336.26, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 79427.01, "10th_percentile": 79427.01, "90th_percentile": 79427.01, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_percentage": 36.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 48450.51, "10th_percentile": 48450.51, "90th_percentile": 48450.51, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_percentage": 39.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 52024.7, "10th_percentile": 52024.7, "90th_percentile": 52024.7, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 31.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41566.79, "10th_percentile": 41566.79, "90th_percentile": 41566.79, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_percentage": 42.8, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 56657.95, "10th_percentile": 56657.95, "90th_percentile": 56657.95, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 39713.57, "10th_percentile": 39713.57, "90th_percentile": 39713.57, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 35.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 46332.43, "10th_percentile": 46332.43, "90th_percentile": 46332.43, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 18930.09, "10th_percentile": 18930.09, "90th_percentile": 18930.09, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_percentage": 31.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 41699.23, "10th_percentile": 41699.23, "90th_percentile": 41699.23, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_percentage": 36.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 48450.51, "10th_percentile": 48450.51, "90th_percentile": 48450.51, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_percentage": 6.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 9134.12, "10th_percentile": 9134.12, "90th_percentile": 9134.12, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 66189.24, "10th_percentile": 66189.24, "90th_percentile": 66189.24, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 101401.85, "10th_percentile": 101401.85, "90th_percentile": 101401.85, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_percentage": 21.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27318.3, "10th_percentile": 27318.3, "90th_percentile": 27318.3, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 105902.68, "10th_percentile": 105902.68, "90th_percentile": 105902.68, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_percentage": 41.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 52688.53, "10th_percentile": 52688.53, "90th_percentile": 52688.53, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_percentage": 41.08, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 4045.0, "10th_percentile": 4045.0, "90th_percentile": 4045.0, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_percentage": 41.08, "standard_charge_algorithm": "Additional drugs and supplies can be included in reimbursement.", "median_amount": 4045.0, "10th_percentile": 4045.0, "90th_percentile": 4045.0, "count": "44", "methodology": "percent of total billed charges" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_percentage": 93.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "44", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 93% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 93% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "44", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - NM HB XR PRC - 3M $0 RETURN & HAS APC FOR CDH & LESSOR OF; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "44", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "44", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price", "median_amount": 15223.51, "10th_percentile": 15223.51, "90th_percentile": 15223.51, "count": "44", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.722048559; Using new claim; Scope: All Financial Classes; Cases: 44; APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $132,378.35 @ 11.5% = $15,223.51 due to $0.00 Claim Price" } ] } ] }, { "description": "B COMPLEX AND C 20-FOLIC ACID 1 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-87637", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60258-0162-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.25, "maximum": 8.75, "setting": "outpatient", "gross_charge": 8.75, "discounted_cash": 6.12, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% 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 Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% 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 Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 5.02, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 5.02, "10th_percentile": 5.02, "90th_percentile": 5.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 4.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 7.98, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 4.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 7.61, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 7.61, "10th_percentile": 7.61, "90th_percentile": 7.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 6.73, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 6.73, "10th_percentile": 6.73, "90th_percentile": 6.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.87, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 7.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 5.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 6.7, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% 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; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 5.62, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5.62, "10th_percentile": 5.62, "90th_percentile": 5.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 3.61, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.61, "10th_percentile": 3.61, "90th_percentile": 3.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 5.85, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.85, "10th_percentile": 5.85, "90th_percentile": 5.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 4.39, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.75, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.75, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 8.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 8.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8.75 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 8.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8.75 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 8.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "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": "CDH BCBS PPO", "standard_charge_dollar": 3.93, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.93, "10th_percentile": 3.93, "90th_percentile": 3.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.59, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.59, "10th_percentile": 3.59, "90th_percentile": 3.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 5.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% 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 Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.59, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.59, "10th_percentile": 3.59, "90th_percentile": 3.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8.75, "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 $8.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "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 $8.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.59, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.59, "10th_percentile": 3.59, "90th_percentile": 3.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3.93, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.93, "10th_percentile": 3.93, "90th_percentile": 3.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 3.59, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.59, "10th_percentile": 3.59, "90th_percentile": 3.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.25, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 2.75, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% 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 Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 4.62, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.62, "10th_percentile": 4.62, "90th_percentile": 4.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 5.04, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.04, "10th_percentile": 5.04, "90th_percentile": 5.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 2.63, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 3.06, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.33, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.33, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.33, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.33, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "BACLOFEN 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-860", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "63739-0479-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.69, "maximum": 24.5, "setting": "outpatient", "gross_charge": 24.5, "discounted_cash": 17.15, "payers_information": [ { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 19.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 19.6, "10th_percentile": 19.6, "90th_percentile": 19.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 19.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 19.6, "10th_percentile": 19.6, "90th_percentile": 19.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 18.77, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 18.77, "10th_percentile": 18.77, "90th_percentile": 18.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 18.84, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 18.84, "10th_percentile": 18.84, "90th_percentile": 18.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 15.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 15.44, "10th_percentile": 15.44, "90th_percentile": 15.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 22.34, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 22.34, "10th_percentile": 22.34, "90th_percentile": 22.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 12.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10.06, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.06, "10th_percentile": 10.06, "90th_percentile": 10.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 10.06, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.06, "10th_percentile": 10.06, "90th_percentile": 10.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4.31, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.31, "10th_percentile": 4.31, "90th_percentile": 4.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 4.31, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.31, "10th_percentile": 4.31, "90th_percentile": 4.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.9, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.9, "10th_percentile": 4.9, "90th_percentile": 4.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4.9, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4.9, "10th_percentile": 4.9, "90th_percentile": 4.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.5, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% 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 Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 8.58, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% 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; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 7.35, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 7.35, "10th_percentile": 7.35, "90th_percentile": 7.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 14.11, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.11, "10th_percentile": 14.11, "90th_percentile": 14.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 7.69, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 12.94, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.94, "10th_percentile": 12.94, "90th_percentile": 12.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 24.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 24.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 24.5, "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 $24.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "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 $24.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 24.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $24.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 24.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1.69, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1.69, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1.69, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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 Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 14.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.72, "10th_percentile": 2.72, "90th_percentile": 2.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24.50 @ 11.5% = $2.82 due to $0.00 Claim Price", "median_amount": 2.82, "10th_percentile": 2.82, "90th_percentile": 2.82, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24.50 @ 11.5% = $2.82 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24.50 @ 11.5% = $2.82 due to $0.00 Claim Price", "median_amount": 2.82, "10th_percentile": 2.82, "90th_percentile": 2.82, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $24.50 @ 11.5% = $2.82 due to $0.00 Claim Price" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 15.74, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 15.74, "10th_percentile": 15.74, "90th_percentile": 15.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 14.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 14.06, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 14.06, "10th_percentile": 14.06, "90th_percentile": 14.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 21.32, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 21.32, "10th_percentile": 21.32, "90th_percentile": 21.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 16.39, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.39, "10th_percentile": 16.39, "90th_percentile": 16.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 12.3, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.3, "10th_percentile": 12.3, "90th_percentile": 12.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 24.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 24.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 24.5, "10th_percentile": 24.5, "90th_percentile": 24.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BAG URINE DRAINAGE 154102", "code_information": [ { "code": "SUP-302799", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 7.77, "maximum": 54.32, "setting": "outpatient", "gross_charge": 54.32, "discounted_cash": 38.02, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.68, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.68, "10th_percentile": 20.68, "90th_percentile": 20.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.68, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.68, "10th_percentile": 20.68, "90th_percentile": 20.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 20.68, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.68, "10th_percentile": 20.68, "90th_percentile": 20.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 20.68, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.68, "10th_percentile": 20.68, "90th_percentile": 20.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 32.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 32.59, "10th_percentile": 32.59, "90th_percentile": 32.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 32.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 32.59, "10th_percentile": 32.59, "90th_percentile": 32.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 32.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 32.59, "10th_percentile": 32.59, "90th_percentile": 32.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $54.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $54.32 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $54.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $54.32 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $54.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $54.32 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 54.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 17.06, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 17.06, "10th_percentile": 17.06, "90th_percentile": 17.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 31.29, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.29, "10th_percentile": 31.29, "90th_percentile": 31.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 7.77, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 16.3, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 16.3, "10th_percentile": 16.3, "90th_percentile": 16.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 19.01, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 19.01, "10th_percentile": 19.01, "90th_percentile": 19.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 28.68, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22.29, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.29, "10th_percentile": 22.29, "90th_percentile": 22.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 22.29, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.29, "10th_percentile": 22.29, "90th_percentile": 22.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 10.86, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 10.86, "10th_percentile": 10.86, "90th_percentile": 10.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 10.86, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 10.86, "10th_percentile": 10.86, "90th_percentile": 10.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 22.31, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 22.31, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 24.37, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.37, "10th_percentile": 24.37, "90th_percentile": 24.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 24.37, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.37, "10th_percentile": 24.37, "90th_percentile": 24.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 32.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 32.59, "10th_percentile": 32.59, "90th_percentile": 32.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 36.34, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.34, "10th_percentile": 36.34, "90th_percentile": 36.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 27.27, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.27, "10th_percentile": 27.27, "90th_percentile": 27.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 49.54, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 49.54, "10th_percentile": 49.54, "90th_percentile": 49.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 34.89, "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": 34.89, "10th_percentile": 34.89, "90th_percentile": 34.89, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 22.43, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.43, "10th_percentile": 22.43, "90th_percentile": 22.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 43.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 43.46, "10th_percentile": 43.46, "90th_percentile": 43.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 27.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 27.16, "10th_percentile": 27.16, "90th_percentile": 27.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 11.62, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.62, "10th_percentile": 11.62, "90th_percentile": 11.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 31.18, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 31.18, "10th_percentile": 31.18, "90th_percentile": 31.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 47.26, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 47.26, "10th_percentile": 47.26, "90th_percentile": 47.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 34.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 34.22, "10th_percentile": 34.22, "90th_percentile": 34.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 41.77, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 41.77, "10th_percentile": 41.77, "90th_percentile": 41.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 41.61, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 41.61, "10th_percentile": 41.61, "90th_percentile": 41.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 43.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 43.46, "10th_percentile": 43.46, "90th_percentile": 43.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 27.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.16, "10th_percentile": 27.16, "90th_percentile": 27.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.32, "10th_percentile": 54.32, "90th_percentile": 54.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BALLN R2P METACROSS RX PTA 035 200CM 6FR 5X100MM", "code_information": [ { "code": "SUP-391154", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 247.7, "maximum": 3589.83, "setting": "outpatient", "gross_charge": 3589.83, "discounted_cash": 2512.88, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2401.6, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2401.6, "10th_percentile": 2401.6, "90th_percentile": 2401.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1802.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1802.09, "10th_percentile": 1802.09, "90th_percentile": 1802.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1482.6, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2060.56, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2060.56, "10th_percentile": 2060.56, "90th_percentile": 2060.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2305.75, "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": 2305.75, "10th_percentile": 2305.75, "90th_percentile": 2305.75, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3123.15, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3123.15, "10th_percentile": 3123.15, "90th_percentile": 3123.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2261.59, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2261.59, "10th_percentile": 2261.59, "90th_percentile": 2261.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1794.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1794.92, "10th_percentile": 1794.92, "90th_percentile": 1794.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2760.58, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2760.58, "10th_percentile": 2760.58, "90th_percentile": 2760.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2871.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2871.86, "10th_percentile": 2871.86, "90th_percentile": 2871.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2749.81, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2749.81, "10th_percentile": 2749.81, "90th_percentile": 2749.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3273.92, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3273.92, "10th_percentile": 3273.92, "90th_percentile": 3273.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 768.22, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.22, "10th_percentile": 768.22, "90th_percentile": 768.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2871.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2871.86, "10th_percentile": 2871.86, "90th_percentile": 2871.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1794.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1794.92, "10th_percentile": 1794.92, "90th_percentile": 1794.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1895.43, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1895.43, "10th_percentile": 1895.43, "90th_percentile": 1895.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1256.44, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1256.44, "10th_percentile": 1256.44, "90th_percentile": 1256.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1076.95, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1076.95, "10th_percentile": 1076.95, "90th_percentile": 1076.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1127.21, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1127.21, "10th_percentile": 1127.21, "90th_percentile": 1127.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 513.35, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 513.35, "10th_percentile": 513.35, "90th_percentile": 513.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2067.74, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2067.74, "10th_percentile": 2067.74, "90th_percentile": 2067.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 631.81, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 631.81, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1474.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1474.7, "10th_percentile": 1474.7, "90th_percentile": 1474.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1474.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1474.7, "10th_percentile": 1474.7, "90th_percentile": 1474.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price", "median_amount": 412.83, "10th_percentile": 412.83, "90th_percentile": 412.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price", "median_amount": 412.83, "10th_percentile": 412.83, "90th_percentile": 412.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BALLN R2P METACROSS RX PTA 035 200CM 6FR 5X40MM", "code_information": [ { "code": "SUP-391153", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 247.7, "maximum": 3589.83, "setting": "outpatient", "gross_charge": 3589.83, "discounted_cash": 2512.88, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1474.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1474.7, "10th_percentile": 1474.7, "90th_percentile": 1474.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1474.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1474.7, "10th_percentile": 1474.7, "90th_percentile": 1474.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 631.81, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 631.81, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1076.95, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1076.95, "10th_percentile": 1076.95, "90th_percentile": 1076.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2067.74, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2067.74, "10th_percentile": 2067.74, "90th_percentile": 2067.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 513.35, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 513.35, "10th_percentile": 513.35, "90th_percentile": 513.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1895.43, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1895.43, "10th_percentile": 1895.43, "90th_percentile": 1895.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1127.21, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1127.21, "10th_percentile": 1127.21, "90th_percentile": 1127.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1256.44, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1256.44, "10th_percentile": 1256.44, "90th_percentile": 1256.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1482.6, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1794.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1794.92, "10th_percentile": 1794.92, "90th_percentile": 1794.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2871.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2871.86, "10th_percentile": 2871.86, "90th_percentile": 2871.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2871.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2871.86, "10th_percentile": 2871.86, "90th_percentile": 2871.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2749.81, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2749.81, "10th_percentile": 2749.81, "90th_percentile": 2749.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 768.22, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.22, "10th_percentile": 768.22, "90th_percentile": 768.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price", "median_amount": 412.83, "10th_percentile": 412.83, "90th_percentile": 412.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2401.6, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2401.6, "10th_percentile": 2401.6, "90th_percentile": 2401.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2060.56, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2060.56, "10th_percentile": 2060.56, "90th_percentile": 2060.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1802.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1802.09, "10th_percentile": 1802.09, "90th_percentile": 1802.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 2305.75, "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": 2305.75, "10th_percentile": 2305.75, "90th_percentile": 2305.75, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3123.15, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3123.15, "10th_percentile": 3123.15, "90th_percentile": 3123.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2261.59, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2261.59, "10th_percentile": 2261.59, "90th_percentile": 2261.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1794.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1794.92, "10th_percentile": 1794.92, "90th_percentile": 1794.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2760.58, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2760.58, "10th_percentile": 2760.58, "90th_percentile": 2760.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3273.92, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3273.92, "10th_percentile": 3273.92, "90th_percentile": 3273.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price", "median_amount": 412.83, "10th_percentile": 412.83, "90th_percentile": 412.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BALLN R2P METACROSS RX PTA 035 200CM 6FR 6X100MM", "code_information": [ { "code": "SUP-391156", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 247.7, "maximum": 3589.83, "setting": "outpatient", "gross_charge": 3589.83, "discounted_cash": 2512.88, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 717.97, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price", "median_amount": 412.83, "10th_percentile": 412.83, "90th_percentile": 412.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price", "median_amount": 412.83, "10th_percentile": 412.83, "90th_percentile": 412.83, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $3,589.83 @ 11.5% = $412.83 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1482.6, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2401.6, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2401.6, "10th_percentile": 2401.6, "90th_percentile": 2401.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 2305.75, "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": 2305.75, "10th_percentile": 2305.75, "90th_percentile": 2305.75, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2060.56, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2060.56, "10th_percentile": 2060.56, "90th_percentile": 2060.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3123.15, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3123.15, "10th_percentile": 3123.15, "90th_percentile": 3123.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2261.59, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2261.59, "10th_percentile": 2261.59, "90th_percentile": 2261.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3273.92, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3273.92, "10th_percentile": 3273.92, "90th_percentile": 3273.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 768.22, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.22, "10th_percentile": 768.22, "90th_percentile": 768.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2749.81, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2749.81, "10th_percentile": 2749.81, "90th_percentile": 2749.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1802.09, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1802.09, "10th_percentile": 1802.09, "90th_percentile": 1802.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2760.58, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2760.58, "10th_percentile": 2760.58, "90th_percentile": 2760.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1794.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1794.92, "10th_percentile": 1794.92, "90th_percentile": 1794.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1794.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1794.92, "10th_percentile": 1794.92, "90th_percentile": 1794.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2871.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2871.86, "10th_percentile": 2871.86, "90th_percentile": 2871.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2871.86, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2871.86, "10th_percentile": 2871.86, "90th_percentile": 2871.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 631.81, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 631.81, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 631.81, "10th_percentile": 631.81, "90th_percentile": 631.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 513.35, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 513.35, "10th_percentile": 513.35, "90th_percentile": 513.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1127.21, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1127.21, "10th_percentile": 1127.21, "90th_percentile": 1127.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1895.43, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1895.43, "10th_percentile": 1895.43, "90th_percentile": 1895.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2067.74, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2067.74, "10th_percentile": 2067.74, "90th_percentile": 2067.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1076.95, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1076.95, "10th_percentile": 1076.95, "90th_percentile": 1076.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1256.44, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1256.44, "10th_percentile": 1256.44, "90th_percentile": 1256.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1474.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1474.7, "10th_percentile": 1474.7, "90th_percentile": 1474.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1474.7, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1474.7, "10th_percentile": 1474.7, "90th_percentile": 1474.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,589.83 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3589.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3589.83, "10th_percentile": 3589.83, "90th_percentile": 3589.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 247.7, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.7, "10th_percentile": 247.7, "90th_percentile": 247.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2153.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2153.9, "10th_percentile": 2153.9, "90th_percentile": 2153.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.47, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 398.47, "10th_percentile": 398.47, "90th_percentile": 398.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "BALLOON CATHETER EVERCROSS 6 X 40 MM .035 X 80 CM OTW", "code_information": [ { "code": "SUP-306729", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 93.15, "maximum": 1350.01, "setting": "outpatient", "gross_charge": 1350.01, "discounted_cash": 945.01, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 149.85, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 149.85, "10th_percentile": 149.85, "90th_percentile": 149.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 149.85, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 149.85, "10th_percentile": 149.85, "90th_percentile": 149.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 149.85, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 149.85, "10th_percentile": 149.85, "90th_percentile": 149.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 810.01, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 810.01, "10th_percentile": 810.01, "90th_percentile": 810.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 554.58, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 554.58, "10th_percentile": 554.58, "90th_percentile": 554.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 237.6, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.6, "10th_percentile": 237.6, "90th_percentile": 237.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 405.0, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 405.0, "10th_percentile": 405.0, "90th_percentile": 405.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 777.61, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 777.61, "10th_percentile": 777.61, "90th_percentile": 777.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 193.05, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 193.05, "10th_percentile": 193.05, "90th_percentile": 193.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 712.81, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 712.81, "10th_percentile": 712.81, "90th_percentile": 712.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 423.9, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 423.9, "10th_percentile": 423.9, "90th_percentile": 423.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 472.5, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 472.5, "10th_percentile": 472.5, "90th_percentile": 472.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,350.01 @ 11.5% = $155.25 due to $0.00 Claim Price", "median_amount": 155.25, "10th_percentile": 155.25, "90th_percentile": 155.25, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,350.01 @ 11.5% = $155.25 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 270.0, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 270.0, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1052.74, "10th_percentile": 1052.74, "90th_percentile": 1052.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 810.01, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 810.01, "10th_percentile": 810.01, "90th_percentile": 810.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 810.01, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 810.01, "10th_percentile": 810.01, "90th_percentile": 810.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 557.55, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 420.07, "10th_percentile": 420.07, "90th_percentile": 420.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 903.16, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 903.16, "10th_percentile": 903.16, "90th_percentile": 903.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 774.91, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 774.91, "10th_percentile": 774.91, "90th_percentile": 774.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 677.71, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 677.71, "10th_percentile": 677.71, "90th_percentile": 677.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 867.11, "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": 867.11, "10th_percentile": 867.11, "90th_percentile": 867.11, "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": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1174.51, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1174.51, "10th_percentile": 1174.51, "90th_percentile": 1174.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 850.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 850.51, "10th_percentile": 850.51, "90th_percentile": 850.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 810.01, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 810.01, "10th_percentile": 810.01, "90th_percentile": 810.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 675.01, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 675.01, "10th_percentile": 675.01, "90th_percentile": 675.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1038.16, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1038.16, "10th_percentile": 1038.16, "90th_percentile": 1038.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1080.01, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1080.01, "10th_percentile": 1080.01, "90th_percentile": 1080.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1034.11, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1034.11, "10th_percentile": 1034.11, "90th_percentile": 1034.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1231.21, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1231.21, "10th_percentile": 1231.21, "90th_percentile": 1231.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 288.9, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 288.9, "10th_percentile": 288.9, "90th_percentile": 288.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1080.01, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1080.01, "10th_percentile": 1080.01, "90th_percentile": 1080.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 675.01, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.01, "10th_percentile": 675.01, "90th_percentile": 675.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 237.6, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.6, "10th_percentile": 237.6, "90th_percentile": 237.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 554.58, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 554.58, "10th_percentile": 554.58, "90th_percentile": 554.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 93.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.15, "10th_percentile": 93.15, "90th_percentile": 93.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 93.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.15, "10th_percentile": 93.15, "90th_percentile": 93.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 93.15, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.15, "10th_percentile": 93.15, "90th_percentile": 93.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,350.01 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,350.01 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,350.01 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,350.01 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1350.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,350.01 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,350.01 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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 149.85, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 149.85, "10th_percentile": 149.85, "90th_percentile": 149.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 149.85, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 149.85, "10th_percentile": 149.85, "90th_percentile": 149.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 149.85, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 149.85, "10th_percentile": 149.85, "90th_percentile": 149.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,350.01 @ 11.5% = $155.25 due to $0.00 Claim Price", "median_amount": 155.25, "10th_percentile": 155.25, "90th_percentile": 155.25, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $1,350.01 @ 11.5% = $155.25 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1350.01, "10th_percentile": 1350.01, "90th_percentile": 1350.01, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BANDAGE D STAT HEMOSTATIC", "code_information": [ { "code": "SUP-321553", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 68.79, "maximum": 481.04, "setting": "outpatient", "gross_charge": 481.04, "discounted_cash": 336.73, "payers_information": [ { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 288.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 288.62, "10th_percentile": 288.62, "90th_percentile": 288.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 96.21, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 96.21, "10th_percentile": 96.21, "90th_percentile": 96.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 321.82, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.82, "10th_percentile": 321.82, "90th_percentile": 321.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 240.52, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 240.52, "10th_percentile": 240.52, "90th_percentile": 240.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 241.48, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 241.48, "10th_percentile": 241.48, "90th_percentile": 241.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 276.12, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 276.12, "10th_percentile": 276.12, "90th_percentile": 276.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 303.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 303.06, "10th_percentile": 303.06, "90th_percentile": 303.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 308.97, "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": 308.97, "10th_percentile": 308.97, "90th_percentile": 308.97, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 288.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 288.62, "10th_percentile": 288.62, "90th_percentile": 288.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 438.71, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 438.71, "10th_percentile": 438.71, "90th_percentile": 438.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 418.5, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 418.5, "10th_percentile": 418.5, "90th_percentile": 418.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "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": "CDH ADVOCATE IPA", "standard_charge_dollar": 288.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 288.62, "10th_percentile": 288.62, "90th_percentile": 288.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 215.79, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.79, "10th_percentile": 215.79, "90th_percentile": 215.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 197.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.61, "10th_percentile": 197.61, "90th_percentile": 197.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 96.21, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 96.21, "10th_percentile": 96.21, "90th_percentile": 96.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 197.37, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.37, "10th_percentile": 197.37, "90th_percentile": 197.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $481.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $481.04 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $481.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $481.04 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $481.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $481.04 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 481.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 183.13, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.13, "10th_percentile": 183.13, "90th_percentile": 183.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 183.13, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.13, "10th_percentile": 183.13, "90th_percentile": 183.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 253.99, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.99, "10th_percentile": 253.99, "90th_percentile": 253.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 277.08, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 277.08, "10th_percentile": 277.08, "90th_percentile": 277.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 151.05, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 151.05, "10th_percentile": 151.05, "90th_percentile": 151.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 144.31, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 144.31, "10th_percentile": 144.31, "90th_percentile": 144.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 68.79, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 68.79, "10th_percentile": 68.79, "90th_percentile": 68.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 168.36, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 168.36, "10th_percentile": 168.36, "90th_percentile": 168.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 369.92, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 369.92, "10th_percentile": 369.92, "90th_percentile": 369.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 384.83, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 384.83, "10th_percentile": 384.83, "90th_percentile": 384.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 197.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.61, "10th_percentile": 197.61, "90th_percentile": 197.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 240.52, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 240.52, "10th_percentile": 240.52, "90th_percentile": 240.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 384.83, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 384.83, "10th_percentile": 384.83, "90th_percentile": 384.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 197.37, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.37, "10th_percentile": 197.37, "90th_percentile": 197.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 102.94, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.94, "10th_percentile": 102.94, "90th_percentile": 102.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 198.67, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 198.67, "10th_percentile": 198.67, "90th_percentile": 198.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 368.48, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 368.48, "10th_percentile": 368.48, "90th_percentile": 368.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 215.79, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.79, "10th_percentile": 215.79, "90th_percentile": 215.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 288.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 288.62, "10th_percentile": 288.62, "90th_percentile": 288.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 183.13, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.13, "10th_percentile": 183.13, "90th_percentile": 183.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 183.13, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 183.13, "10th_percentile": 183.13, "90th_percentile": 183.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 481.04, "10th_percentile": 481.04, "90th_percentile": 481.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BANDAGE FOAM COFLEX LF2 4IN 5YD TAN STERILE", "code_information": [ { "code": "SUP-416682", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 8.1, "maximum": 56.64, "setting": "outpatient", "gross_charge": 56.64, "discounted_cash": 39.65, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 17.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 17.78, "10th_percentile": 17.78, "90th_percentile": 17.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 32.62, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.62, "10th_percentile": 32.62, "90th_percentile": 32.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 8.1, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% 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; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 16.99, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 16.99, "10th_percentile": 16.99, "90th_percentile": 16.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 19.82, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 19.82, "10th_percentile": 19.82, "90th_percentile": 19.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 29.91, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.91, "10th_percentile": 29.91, "90th_percentile": 29.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 33.98, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 33.98, "10th_percentile": 33.98, "90th_percentile": 33.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 25.41, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.41, "10th_percentile": 25.41, "90th_percentile": 25.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 23.27, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 11.33, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 11.33, "10th_percentile": 11.33, "90th_percentile": 11.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 23.24, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.24, "10th_percentile": 23.24, "90th_percentile": 23.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 56.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $56.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $56.64 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 56.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $56.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $56.64 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 56.64, "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 $56.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "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 $56.64 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 56.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 21.56, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.56, "10th_percentile": 21.56, "90th_percentile": 21.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 21.56, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.56, "10th_percentile": 21.56, "90th_percentile": 21.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 56.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 56.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 56.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 28.43, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.43, "10th_percentile": 28.43, "90th_percentile": 28.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 43.56, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 43.56, "10th_percentile": 43.56, "90th_percentile": 43.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 36.38, "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": 36.38, "10th_percentile": 36.38, "90th_percentile": 36.38, "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": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 37.89, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.89, "10th_percentile": 37.89, "90th_percentile": 37.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 51.66, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 51.66, "10th_percentile": 51.66, "90th_percentile": 51.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 45.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 45.31, "10th_percentile": 45.31, "90th_percentile": 45.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 23.27, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 32.51, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 32.51, "10th_percentile": 32.51, "90th_percentile": 32.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 33.98, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 33.98, "10th_percentile": 33.98, "90th_percentile": 33.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 28.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.32, "10th_percentile": 28.32, "90th_percentile": 28.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 45.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 45.31, "10th_percentile": 45.31, "90th_percentile": 45.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 23.24, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.24, "10th_percentile": 23.24, "90th_percentile": 23.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 11.33, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 11.33, "10th_percentile": 11.33, "90th_percentile": 11.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 12.12, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.12, "10th_percentile": 12.12, "90th_percentile": 12.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 49.28, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 49.28, "10th_percentile": 49.28, "90th_percentile": 49.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 23.39, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.39, "10th_percentile": 23.39, "90th_percentile": 23.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 43.39, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 43.39, "10th_percentile": 43.39, "90th_percentile": 43.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 28.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 28.32, "10th_percentile": 28.32, "90th_percentile": 28.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 35.68, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 35.68, "10th_percentile": 35.68, "90th_percentile": 35.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 25.41, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.41, "10th_percentile": 25.41, "90th_percentile": 25.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 33.98, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 33.98, "10th_percentile": 33.98, "90th_percentile": 33.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 33.98, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 33.98, "10th_percentile": 33.98, "90th_percentile": 33.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 21.56, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.56, "10th_percentile": 21.56, "90th_percentile": 21.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 21.56, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.56, "10th_percentile": 21.56, "90th_percentile": 21.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 56.64, "10th_percentile": 56.64, "90th_percentile": 56.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BARD EAGLE INFLATION DEVICE 10CC (325110)", "code_information": [ { "code": "SUP-302854", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 242.73, "maximum": 1697.38, "setting": "outpatient", "gross_charge": 1697.38, "discounted_cash": 1188.17, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 646.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.19, "10th_percentile": 646.19, "90th_percentile": 646.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 646.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.19, "10th_percentile": 646.19, "90th_percentile": 646.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 646.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.19, "10th_percentile": 646.19, "90th_percentile": 646.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 646.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.19, "10th_percentile": 646.19, "90th_percentile": 646.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1018.43, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1018.43, "10th_percentile": 1018.43, "90th_percentile": 1018.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1018.43, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1018.43, "10th_percentile": 1018.43, "90th_percentile": 1018.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1018.43, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1018.43, "10th_percentile": 1018.43, "90th_percentile": 1018.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1697.38, "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 $1,697.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "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 $1,697.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1697.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,697.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,697.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1697.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,697.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,697.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1697.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1697.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1697.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1697.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 532.98, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 532.98, "10th_percentile": 532.98, "90th_percentile": 532.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 977.69, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 977.69, "10th_percentile": 977.69, "90th_percentile": 977.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 242.73, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 242.73, "10th_percentile": 242.73, "90th_percentile": 242.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 509.21, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 509.21, "10th_percentile": 509.21, "90th_percentile": 509.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 594.08, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 594.08, "10th_percentile": 594.08, "90th_percentile": 594.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 896.22, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 896.22, "10th_percentile": 896.22, "90th_percentile": 896.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 696.44, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 696.44, "10th_percentile": 696.44, "90th_percentile": 696.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 696.44, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 696.44, "10th_percentile": 696.44, "90th_percentile": 696.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 339.48, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 339.48, "10th_percentile": 339.48, "90th_percentile": 339.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 339.48, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 339.48, "10th_percentile": 339.48, "90th_percentile": 339.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 697.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 697.28, "10th_percentile": 697.28, "90th_percentile": 697.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 697.28, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 697.28, "10th_percentile": 697.28, "90th_percentile": 697.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 761.44, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 761.44, "10th_percentile": 761.44, "90th_percentile": 761.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 761.44, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 761.44, "10th_percentile": 761.44, "90th_percentile": 761.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1018.43, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1018.43, "10th_percentile": 1018.43, "90th_percentile": 1018.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1135.55, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1135.55, "10th_percentile": 1135.55, "90th_percentile": 1135.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 852.08, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 852.08, "10th_percentile": 852.08, "90th_percentile": 852.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 1548.01, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1548.01, "10th_percentile": 1548.01, "90th_percentile": 1548.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1090.23, "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": 1090.23, "10th_percentile": 1090.23, "90th_percentile": 1090.23, "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": "CDH CIGNA BROAD", "standard_charge_dollar": 701.02, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 701.02, "10th_percentile": 701.02, "90th_percentile": 701.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1357.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1357.9, "10th_percentile": 1357.9, "90th_percentile": 1357.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 848.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 848.69, "10th_percentile": 848.69, "90th_percentile": 848.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 363.24, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.24, "10th_percentile": 363.24, "90th_percentile": 363.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 974.3, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 974.3, "10th_percentile": 974.3, "90th_percentile": 974.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1476.72, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1476.72, "10th_percentile": 1476.72, "90th_percentile": 1476.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1069.35, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1069.35, "10th_percentile": 1069.35, "90th_percentile": 1069.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1305.29, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1305.29, "10th_percentile": 1305.29, "90th_percentile": 1305.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1300.19, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1300.19, "10th_percentile": 1300.19, "90th_percentile": 1300.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1357.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1357.9, "10th_percentile": 1357.9, "90th_percentile": 1357.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 848.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 848.69, "10th_percentile": 848.69, "90th_percentile": 848.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1697.38, "10th_percentile": 1697.38, "90th_percentile": 1697.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BARD VIKING DIAG CS DECAPOLAR CATH FIXED CURVE 6FR", "code_information": [ { "code": "SUP-120964", "type": "CDM" }, { "code": "C1730", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 140.36, "maximum": 2034.24, "setting": "outpatient", "gross_charge": 2034.24, "discounted_cash": 1423.97, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 711.98, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 711.98, "10th_percentile": 711.98, "90th_percentile": 711.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 290.9, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 290.9, "10th_percentile": 290.9, "90th_percentile": 290.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1171.72, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.72, "10th_percentile": 1171.72, "90th_percentile": 1171.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1074.08, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1074.08, "10th_percentile": 1074.08, "90th_percentile": 1074.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 610.27, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 610.27, "10th_percentile": 610.27, "90th_percentile": 610.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 638.75, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 638.75, "10th_percentile": 638.75, "90th_percentile": 638.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 835.67, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 835.67, "10th_percentile": 835.67, "90th_percentile": 835.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 835.67, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 835.67, "10th_percentile": 835.67, "90th_percentile": 835.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 358.03, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.03, "10th_percentile": 358.03, "90th_percentile": 358.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1220.54, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1220.54, "10th_percentile": 1220.54, "90th_percentile": 1220.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 225.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 225.8, "10th_percentile": 225.8, "90th_percentile": 225.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 225.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 225.8, "10th_percentile": 225.8, "90th_percentile": 225.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 225.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 225.8, "10th_percentile": 225.8, "90th_percentile": 225.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 225.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 225.8, "10th_percentile": 225.8, "90th_percentile": 225.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 225.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 225.8, "10th_percentile": 225.8, "90th_percentile": 225.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 225.8, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 225.8, "10th_percentile": 225.8, "90th_percentile": 225.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,034.24 @ 11.5% = $233.94 due to $0.00 Claim Price", "median_amount": 233.94, "10th_percentile": 233.94, "90th_percentile": 233.94, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,034.24 @ 11.5% = $233.94 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "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": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 406.85, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 406.85, "10th_percentile": 406.85, "90th_percentile": 406.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 406.85, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 406.85, "10th_percentile": 406.85, "90th_percentile": 406.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 1558.23, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1558.23, "10th_percentile": 1558.23, "90th_percentile": 1558.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 435.33, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 435.33, "10th_percentile": 435.33, "90th_percentile": 435.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1627.39, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1627.39, "10th_percentile": 1627.39, "90th_percentile": 1627.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 840.14, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 840.14, "10th_percentile": 840.14, "90th_percentile": 840.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1627.39, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1627.39, "10th_percentile": 1627.39, "90th_percentile": 1627.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1564.33, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1564.33, "10th_percentile": 1564.33, "90th_percentile": 1564.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1855.23, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1855.23, "10th_percentile": 1855.23, "90th_percentile": 1855.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1017.12, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1017.12, "10th_percentile": 1017.12, "90th_percentile": 1017.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1281.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1281.57, "10th_percentile": 1281.57, "90th_percentile": 1281.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1220.54, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1220.54, "10th_percentile": 1220.54, "90th_percentile": 1220.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1769.79, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1769.79, "10th_percentile": 1769.79, "90th_percentile": 1769.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1167.65, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1167.65, "10th_percentile": 1167.65, "90th_percentile": 1167.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1306.59, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1306.59, "10th_percentile": 1306.59, "90th_percentile": 1306.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH UHC CORE", "standard_charge_dollar": 1021.19, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1021.19, "10th_percentile": 1021.19, "90th_percentile": 1021.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1360.91, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1360.91, "10th_percentile": 1360.91, "90th_percentile": 1360.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 358.03, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.03, "10th_percentile": 358.03, "90th_percentile": 358.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,034.24 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,034.24 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,034.24 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,034.24 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,034.24 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,034.24 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2034.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1220.54, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1220.54, "10th_percentile": 1220.54, "90th_percentile": 1220.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1220.54, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1220.54, "10th_percentile": 1220.54, "90th_percentile": 1220.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 140.36, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.36, "10th_percentile": 140.36, "90th_percentile": 140.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 140.36, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.36, "10th_percentile": 140.36, "90th_percentile": 140.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 140.36, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.36, "10th_percentile": 140.36, "90th_percentile": 140.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,034.24 @ 11.5% = $233.94 due to $0.00 Claim Price", "median_amount": 233.94, "10th_percentile": 233.94, "90th_percentile": 233.94, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2,034.24 @ 11.5% = $233.94 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2034.24, "10th_percentile": 2034.24, "90th_percentile": 2034.24, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BASEPLATE TIB REV LEGN SZ 5 L", "code_information": [ { "code": "SUP-132062", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1465.29, "maximum": 21236.03, "setting": "outpatient", "gross_charge": 21236.03, "discounted_cash": 14865.22, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 3036.75, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 14206.9, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 16988.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 16988.82, "10th_percentile": 16988.82, "90th_percentile": 16988.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 10660.49, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10660.49, "10th_percentile": 10660.49, "90th_percentile": 10660.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 10618.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 10618.02, "10th_percentile": 10618.02, "90th_percentile": 10618.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 13378.7, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 13378.7, "10th_percentile": 13378.7, "90th_percentile": 13378.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 10618.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10618.02, "10th_percentile": 10618.02, "90th_percentile": 10618.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 16266.8, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 16266.8, "10th_percentile": 16266.8, "90th_percentile": 16266.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 12189.48, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 12189.48, "10th_percentile": 12189.48, "90th_percentile": 12189.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 4544.51, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4544.51, "10th_percentile": 4544.51, "90th_percentile": 4544.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 12741.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 12741.62, "10th_percentile": 12741.62, "90th_percentile": 12741.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 18475.35, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 18475.35, "10th_percentile": 18475.35, "90th_percentile": 18475.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 13639.9, "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": 13639.9, "10th_percentile": 13639.9, "90th_percentile": 13639.9, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 16988.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 16988.82, "10th_percentile": 16988.82, "90th_percentile": 16988.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 19367.26, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 19367.26, "10th_percentile": 19367.26, "90th_percentile": 19367.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 16330.51, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 16330.51, "10th_percentile": 16330.51, "90th_percentile": 16330.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 8770.48, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 7432.61, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 7432.61, "10th_percentile": 7432.61, "90th_percentile": 7432.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 6668.11, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 6668.11, "10th_percentile": 6668.11, "90th_percentile": 6668.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 11212.62, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11212.62, "10th_percentile": 11212.62, "90th_percentile": 11212.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 12231.95, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12231.95, "10th_percentile": 12231.95, "90th_percentile": 12231.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 6370.81, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 6370.81, "10th_percentile": 6370.81, "90th_percentile": 6370.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4247.21, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4247.21, "10th_percentile": 4247.21, "90th_percentile": 4247.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 4247.21, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 4247.21, "10th_percentile": 4247.21, "90th_percentile": 4247.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3737.54, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3737.54, "10th_percentile": 3737.54, "90th_percentile": 3737.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 3737.54, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3737.54, "10th_percentile": 3737.54, "90th_percentile": 3737.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8723.76, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8723.76, "10th_percentile": 8723.76, "90th_percentile": 8723.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 8723.76, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8723.76, "10th_percentile": 8723.76, "90th_percentile": 8723.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 21236.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 21236.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 21236.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 21236.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21,236.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21,236.03 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 21236.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21,236.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $21,236.03 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 21236.03, "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 $21,236.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "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 $21,236.03 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 21236.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1465.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1465.29, "10th_percentile": 1465.29, "90th_percentile": 1465.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1465.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1465.29, "10th_percentile": 1465.29, "90th_percentile": 1465.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 1465.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1465.29, "10th_percentile": 1465.29, "90th_percentile": 1465.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12741.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12741.62, "10th_percentile": 12741.62, "90th_percentile": 12741.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12741.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12741.62, "10th_percentile": 12741.62, "90th_percentile": 12741.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 12741.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 12741.62, "10th_percentile": 12741.62, "90th_percentile": 12741.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2357.2, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2357.2, "10th_percentile": 2357.2, "90th_percentile": 2357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2357.2, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2357.2, "10th_percentile": 2357.2, "90th_percentile": 2357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2357.2, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2357.2, "10th_percentile": 2357.2, "90th_percentile": 2357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2357.2, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2357.2, "10th_percentile": 2357.2, "90th_percentile": 2357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2357.2, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2357.2, "10th_percentile": 2357.2, "90th_percentile": 2357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2357.2, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 2357.2, "10th_percentile": 2357.2, "90th_percentile": 2357.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $21,236.03 @ 11.5% = $2,442.14 due to $0.00 Claim Price", "median_amount": 2442.14, "10th_percentile": 2442.14, "90th_percentile": 2442.14, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $21,236.03 @ 11.5% = $2,442.14 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $21,236.03 @ 11.5% = $2,442.14 due to $0.00 Claim Price", "median_amount": 2442.14, "10th_percentile": 2442.14, "90th_percentile": 2442.14, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $21,236.03 @ 11.5% = $2,442.14 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21236.03, "10th_percentile": 21236.03, "90th_percentile": 21236.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BASEPLATE TIB STEM CEM PERSONA SZ D 5DEG R", "code_information": [ { "code": "SUP-146058", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 436.14, "maximum": 6320.94, "setting": "outpatient", "gross_charge": 6320.94, "discounted_cash": 4424.66, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 4228.71, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 3173.11, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3173.11, "10th_percentile": 3173.11, "90th_percentile": 3173.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 4059.94, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4059.94, "10th_percentile": 4059.94, "90th_percentile": 4059.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 903.89, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1352.68, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1352.68, "10th_percentile": 1352.68, "90th_percentile": 1352.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 5056.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 5056.75, "10th_percentile": 5056.75, "90th_percentile": 5056.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5499.22, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5499.22, "10th_percentile": 5499.22, "90th_percentile": 5499.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 3160.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3160.47, "10th_percentile": 3160.47, "90th_percentile": 3160.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3628.22, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3628.22, "10th_percentile": 3628.22, "90th_percentile": 3628.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 4841.84, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 4841.84, "10th_percentile": 4841.84, "90th_percentile": 4841.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 5764.7, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 5764.7, "10th_percentile": 5764.7, "90th_percentile": 5764.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 3160.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 3160.47, "10th_percentile": 3160.47, "90th_percentile": 3160.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5056.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5056.75, "10th_percentile": 5056.75, "90th_percentile": 5056.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4860.8, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4860.8, "10th_percentile": 4860.8, "90th_percentile": 4860.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2610.55, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3982.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3982.19, "10th_percentile": 3982.19, "90th_percentile": 3982.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3640.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3640.86, "10th_percentile": 3640.86, "90th_percentile": 3640.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3337.46, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3337.46, "10th_percentile": 3337.46, "90th_percentile": 3337.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1984.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1984.78, "10th_percentile": 1984.78, "90th_percentile": 1984.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2212.33, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2212.33, "10th_percentile": 2212.33, "90th_percentile": 2212.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1896.28, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1896.28, "10th_percentile": 1896.28, "90th_percentile": 1896.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1264.19, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1264.19, "10th_percentile": 1264.19, "90th_percentile": 1264.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1264.19, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1264.19, "10th_percentile": 1264.19, "90th_percentile": 1264.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1112.49, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1112.49, "10th_percentile": 1112.49, "90th_percentile": 1112.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1112.49, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1112.49, "10th_percentile": 1112.49, "90th_percentile": 1112.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2596.64, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.64, "10th_percentile": 2596.64, "90th_percentile": 2596.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2596.64, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.64, "10th_percentile": 2596.64, "90th_percentile": 2596.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6320.94, "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 $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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 $6,320.94 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price", "median_amount": 726.91, "10th_percentile": 726.91, "90th_percentile": 726.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price", "median_amount": 726.91, "10th_percentile": 726.91, "90th_percentile": 726.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BASEPLATE TIB STEM CEM PERSONA SZ H 5DEG L", "code_information": [ { "code": "SUP-147637", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 436.14, "maximum": 6320.94, "setting": "outpatient", "gross_charge": 6320.94, "discounted_cash": 4424.66, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 903.89, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price", "median_amount": 726.91, "10th_percentile": 726.91, "90th_percentile": 726.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price", "median_amount": 726.91, "10th_percentile": 726.91, "90th_percentile": 726.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5056.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5056.75, "10th_percentile": 5056.75, "90th_percentile": 5056.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 4841.84, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 4841.84, "10th_percentile": 4841.84, "90th_percentile": 4841.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4860.8, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4860.8, "10th_percentile": 4860.8, "90th_percentile": 4860.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 3160.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3160.47, "10th_percentile": 3160.47, "90th_percentile": 3160.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 5764.7, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 5764.7, "10th_percentile": 5764.7, "90th_percentile": 5764.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3982.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3982.19, "10th_percentile": 3982.19, "90th_percentile": 3982.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2596.64, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.64, "10th_percentile": 2596.64, "90th_percentile": 2596.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1112.49, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1112.49, "10th_percentile": 1112.49, "90th_percentile": 1112.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 3160.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 3160.47, "10th_percentile": 3160.47, "90th_percentile": 3160.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1264.19, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1264.19, "10th_percentile": 1264.19, "90th_percentile": 1264.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1352.68, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1352.68, "10th_percentile": 1352.68, "90th_percentile": 1352.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 5056.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 5056.75, "10th_percentile": 5056.75, "90th_percentile": 5056.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2610.55, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1984.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1984.78, "10th_percentile": 1984.78, "90th_percentile": 1984.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2212.33, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2212.33, "10th_percentile": 2212.33, "90th_percentile": 2212.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3337.46, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3337.46, "10th_percentile": 3337.46, "90th_percentile": 3337.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1896.28, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1896.28, "10th_percentile": 1896.28, "90th_percentile": 1896.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3640.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3640.86, "10th_percentile": 3640.86, "90th_percentile": 3640.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1112.49, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1112.49, "10th_percentile": 1112.49, "90th_percentile": 1112.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1264.19, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1264.19, "10th_percentile": 1264.19, "90th_percentile": 1264.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2596.64, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.64, "10th_percentile": 2596.64, "90th_percentile": 2596.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6320.94, "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 $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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 $6,320.94 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 4228.71, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 3173.11, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3173.11, "10th_percentile": 3173.11, "90th_percentile": 3173.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 4059.94, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4059.94, "10th_percentile": 4059.94, "90th_percentile": 4059.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5499.22, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5499.22, "10th_percentile": 5499.22, "90th_percentile": 5499.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3628.22, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3628.22, "10th_percentile": 3628.22, "90th_percentile": 3628.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BASEPLATE TIB STEM CEM PERSONA SZ H 5DEG R", "code_information": [ { "code": "SUP-147638", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 436.14, "maximum": 6320.94, "setting": "outpatient", "gross_charge": 6320.94, "discounted_cash": 4424.66, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 903.89, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price", "median_amount": 726.91, "10th_percentile": 726.91, "90th_percentile": 726.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price", "median_amount": 726.91, "10th_percentile": 726.91, "90th_percentile": 726.91, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $6,320.94 @ 11.5% = $726.91 due to $0.00 Claim Price" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 701.62, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 701.62, "10th_percentile": 701.62, "90th_percentile": 701.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 436.14, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.14, "10th_percentile": 436.14, "90th_percentile": 436.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 3173.11, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3173.11, "10th_percentile": 3173.11, "90th_percentile": 3173.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5056.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 5056.75, "10th_percentile": 5056.75, "90th_percentile": 5056.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5499.22, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5499.22, "10th_percentile": 5499.22, "90th_percentile": 5499.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 4059.94, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4059.94, "10th_percentile": 4059.94, "90th_percentile": 4059.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH CHOICE CARE", "standard_charge_dollar": 4841.84, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 4841.84, "10th_percentile": 4841.84, "90th_percentile": 4841.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4860.8, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4860.8, "10th_percentile": 4860.8, "90th_percentile": 4860.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3628.22, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3628.22, "10th_percentile": 3628.22, "90th_percentile": 3628.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 3160.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3160.47, "10th_percentile": 3160.47, "90th_percentile": 3160.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 5764.7, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 5764.7, "10th_percentile": 5764.7, "90th_percentile": 5764.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3982.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3982.19, "10th_percentile": 3982.19, "90th_percentile": 3982.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2596.64, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.64, "10th_percentile": 2596.64, "90th_percentile": 2596.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1112.49, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1112.49, "10th_percentile": 1112.49, "90th_percentile": 1112.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 3160.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 3160.47, "10th_percentile": 3160.47, "90th_percentile": 3160.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1264.19, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1264.19, "10th_percentile": 1264.19, "90th_percentile": 1264.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1352.68, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1352.68, "10th_percentile": 1352.68, "90th_percentile": 1352.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 5056.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 5056.75, "10th_percentile": 5056.75, "90th_percentile": 5056.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 4228.71, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2610.55, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1984.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1984.78, "10th_percentile": 1984.78, "90th_percentile": 1984.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2212.33, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 2212.33, "10th_percentile": 2212.33, "90th_percentile": 2212.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3337.46, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3337.46, "10th_percentile": 3337.46, "90th_percentile": 3337.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1896.28, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1896.28, "10th_percentile": 1896.28, "90th_percentile": 1896.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3640.86, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3640.86, "10th_percentile": 3640.86, "90th_percentile": 3640.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1112.49, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1112.49, "10th_percentile": 1112.49, "90th_percentile": 1112.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1264.19, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1264.19, "10th_percentile": 1264.19, "90th_percentile": 1264.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2596.64, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2596.64, "10th_percentile": 2596.64, "90th_percentile": 2596.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3792.56, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3792.56, "10th_percentile": 3792.56, "90th_percentile": 3792.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6320.94, "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 $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "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 $6,320.94 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 6320.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6320.94, "10th_percentile": 6320.94, "90th_percentile": 6320.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,320.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount." } ] } ] }, { "description": "BASKET ZERO TIP NITINOL STONE RETRIEVAL 1.9FR M0063901050", "code_information": [ { "code": "SUP-104215", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 441.65, "maximum": 3088.47, "setting": "outpatient", "gross_charge": 3088.47, "discounted_cash": 2161.93, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1853.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1853.08, "10th_percentile": 1853.08, "90th_percentile": 1853.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1385.49, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1385.49, "10th_percentile": 1385.49, "90th_percentile": 1385.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1268.74, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1268.74, "10th_percentile": 1268.74, "90th_percentile": 1268.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 617.69, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 617.69, "10th_percentile": 617.69, "90th_percentile": 617.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1267.2, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1267.2, "10th_percentile": 1267.2, "90th_percentile": 1267.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3088.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,088.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,088.47 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3088.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,088.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,088.47 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3088.47, "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 $3,088.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "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 $3,088.47 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3088.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1175.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1175.78, "10th_percentile": 1175.78, "90th_percentile": 1175.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1175.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1175.78, "10th_percentile": 1175.78, "90th_percentile": 1175.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1630.71, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1630.71, "10th_percentile": 1630.71, "90th_percentile": 1630.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1778.96, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1778.96, "10th_percentile": 1778.96, "90th_percentile": 1778.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 969.78, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 969.78, "10th_percentile": 969.78, "90th_percentile": 969.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 926.54, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 926.54, "10th_percentile": 926.54, "90th_percentile": 926.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 441.65, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 441.65, "10th_percentile": 441.65, "90th_percentile": 441.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1080.96, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1080.96, "10th_percentile": 1080.96, "90th_percentile": 1080.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3088.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3088.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3088.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1550.41, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1550.41, "10th_percentile": 1550.41, "90th_percentile": 1550.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2375.03, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2375.03, "10th_percentile": 2375.03, "90th_percentile": 2375.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1983.72, "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": 1983.72, "10th_percentile": 1983.72, "90th_percentile": 1983.72, "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": "CDH UHC HMO/PPO", "standard_charge_dollar": 2066.19, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2066.19, "10th_percentile": 2066.19, "90th_percentile": 2066.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 2816.68, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2816.68, "10th_percentile": 2816.68, "90th_percentile": 2816.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2470.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2470.78, "10th_percentile": 2470.78, "90th_percentile": 2470.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1268.74, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1268.74, "10th_percentile": 1268.74, "90th_percentile": 1268.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1772.78, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1772.78, "10th_percentile": 1772.78, "90th_percentile": 1772.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1853.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1853.08, "10th_percentile": 1853.08, "90th_percentile": 1853.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1544.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1544.24, "10th_percentile": 1544.24, "90th_percentile": 1544.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2470.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2470.78, "10th_percentile": 2470.78, "90th_percentile": 2470.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1267.2, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1267.2, "10th_percentile": 1267.2, "90th_percentile": 1267.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 617.69, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 617.69, "10th_percentile": 617.69, "90th_percentile": 617.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 660.93, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 660.93, "10th_percentile": 660.93, "90th_percentile": 660.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2686.97, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2686.97, "10th_percentile": 2686.97, "90th_percentile": 2686.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1275.54, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1275.54, "10th_percentile": 1275.54, "90th_percentile": 1275.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2365.77, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2365.77, "10th_percentile": 2365.77, "90th_percentile": 2365.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1544.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1544.24, "10th_percentile": 1544.24, "90th_percentile": 1544.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1945.74, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1945.74, "10th_percentile": 1945.74, "90th_percentile": 1945.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1385.49, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1385.49, "10th_percentile": 1385.49, "90th_percentile": 1385.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1853.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1853.08, "10th_percentile": 1853.08, "90th_percentile": 1853.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1853.08, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1853.08, "10th_percentile": 1853.08, "90th_percentile": 1853.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1175.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1175.78, "10th_percentile": 1175.78, "90th_percentile": 1175.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1175.78, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1175.78, "10th_percentile": 1175.78, "90th_percentile": 1175.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3088.47, "10th_percentile": 3088.47, "90th_percentile": 3088.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BATTERY PACK STERILE (05.000.007.01S)", "code_information": [ { "code": "SUP-125714", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 551.97, "maximum": 3859.93, "setting": "outpatient", "gross_charge": 3859.93, "discounted_cash": 2701.95, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1469.48, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1469.48, "10th_percentile": 1469.48, "90th_percentile": 1469.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1469.48, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1469.48, "10th_percentile": 1469.48, "90th_percentile": 1469.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1469.48, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1469.48, "10th_percentile": 1469.48, "90th_percentile": 1469.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1469.48, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1469.48, "10th_percentile": 1469.48, "90th_percentile": 1469.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1731.56, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1731.56, "10th_percentile": 1731.56, "90th_percentile": 1731.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2315.96, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2315.96, "10th_percentile": 2315.96, "90th_percentile": 2315.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1585.66, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1585.66, "10th_percentile": 1585.66, "90th_percentile": 1585.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 771.99, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 771.99, "10th_percentile": 771.99, "90th_percentile": 771.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1583.73, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1583.73, "10th_percentile": 1583.73, "90th_percentile": 1583.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,859.93 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,859.93 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,859.93 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,859.93 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,859.93 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,859.93 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2315.96, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2315.96, "10th_percentile": 2315.96, "90th_percentile": 2315.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2315.96, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2315.96, "10th_percentile": 2315.96, "90th_percentile": 2315.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1157.98, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1157.98, "10th_percentile": 1157.98, "90th_percentile": 1157.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1350.98, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1350.98, "10th_percentile": 1350.98, "90th_percentile": 1350.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2223.32, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2223.32, "10th_percentile": 2223.32, "90th_percentile": 2223.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 551.97, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 551.97, "10th_percentile": 551.97, "90th_percentile": 551.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2038.04, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2038.04, "10th_percentile": 2038.04, "90th_percentile": 2038.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1212.02, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1212.02, "10th_percentile": 1212.02, "90th_percentile": 1212.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3859.93, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1583.73, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1583.73, "10th_percentile": 1583.73, "90th_percentile": 1583.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1585.66, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1585.66, "10th_percentile": 1585.66, "90th_percentile": 1585.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 771.99, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 771.99, "10th_percentile": 771.99, "90th_percentile": 771.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2582.29, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2582.29, "10th_percentile": 2582.29, "90th_percentile": 2582.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1929.97, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1929.97, "10th_percentile": 1929.97, "90th_percentile": 1929.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1937.68, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1937.68, "10th_percentile": 1937.68, "90th_percentile": 1937.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2215.6, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2215.6, "10th_percentile": 2215.6, "90th_percentile": 2215.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2956.71, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2956.71, "10th_percentile": 2956.71, "90th_percentile": 2956.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1731.56, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1731.56, "10th_percentile": 1731.56, "90th_percentile": 1731.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2431.76, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2431.76, "10th_percentile": 2431.76, "90th_percentile": 2431.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 826.03, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 826.03, "10th_percentile": 826.03, "90th_percentile": 826.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 3087.94, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 3087.94, "10th_percentile": 3087.94, "90th_percentile": 3087.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1594.15, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1594.15, "10th_percentile": 1594.15, "90th_percentile": 1594.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3087.94, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 3087.94, "10th_percentile": 3087.94, "90th_percentile": 3087.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2479.23, "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": 2479.23, "10th_percentile": 2479.23, "90th_percentile": 2479.23, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2315.96, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2315.96, "10th_percentile": 2315.96, "90th_percentile": 2315.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 3520.26, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3520.26, "10th_percentile": 3520.26, "90th_percentile": 3520.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3358.14, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3358.14, "10th_percentile": 3358.14, "90th_percentile": 3358.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2968.29, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2968.29, "10th_percentile": 2968.29, "90th_percentile": 2968.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1929.97, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1929.97, "10th_percentile": 1929.97, "90th_percentile": 1929.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3859.93, "10th_percentile": 3859.93, "90th_percentile": 3859.93, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 5137.63, "maximum": 12003.25, "setting": "inpatient", "gross_charge": 27279.5, "discounted_cash": 19095.65, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; 100% Billed", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services - OON; 100% Billed", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 27279.5, "10th_percentile": 27279.5, "90th_percentile": 27279.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 3900.96, "10th_percentile": 3900.96, "90th_percentile": 3900.96, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All Inpatient Services; 37% Billed", "median_amount": 10093.42, "10th_percentile": 10093.42, "90th_percentile": 10093.42, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All Inpatient Services; 32.6% Billed", "median_amount": 8893.12, "10th_percentile": 8893.12, "90th_percentile": 8893.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; 30% Billed", "median_amount": 8183.85, "10th_percentile": 8183.85, "90th_percentile": 8183.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 16367.71, "10th_percentile": 16367.71, "90th_percentile": 16367.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 16367.71, "10th_percentile": 16367.71, "90th_percentile": 16367.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 16367.71, "10th_percentile": 16367.71, "90th_percentile": 16367.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; IP Services; 92% Billed", "median_amount": 25097.14, "10th_percentile": 25097.14, "90th_percentile": 25097.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; 92% Billed", "median_amount": 25097.14, "10th_percentile": 25097.14, "90th_percentile": 25097.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 13639.76, "10th_percentile": 13639.76, "90th_percentile": 13639.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 13639.76, "10th_percentile": 13639.76, "90th_percentile": 13639.76, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient Services; 63% Billed", "median_amount": 17186.09, "10th_percentile": 17186.09, "90th_percentile": 17186.09, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All Inpatient Services; 75.1% Billed", "median_amount": 20486.9, "10th_percentile": 20486.9, "90th_percentile": 20486.9, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 21823.6, "10th_percentile": 21823.6, "90th_percentile": 21823.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7911.06, "10th_percentile": 7911.06, "90th_percentile": 7911.06, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 15931.22, "10th_percentile": 15931.22, "90th_percentile": 15931.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 23733.17, "10th_percentile": 23733.17, "90th_percentile": 23733.17, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9597.55, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9597.55, "10th_percentile": 9597.55, "90th_percentile": 9597.55, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 12003.25, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 12003.25, "10th_percentile": 12003.25, "90th_percentile": 12003.25, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9053.88, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9053.88, "10th_percentile": 9053.88, "90th_percentile": 9053.88, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9869.02, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9869.02, "10th_percentile": 9869.02, "90th_percentile": 9869.02, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 7642.37, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 7642.37, "10th_percentile": 7642.37, "90th_percentile": 7642.37, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 7642.37, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 7642.37, "10th_percentile": 7642.37, "90th_percentile": 7642.37, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9869.02, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9869.02, "10th_percentile": 9869.02, "90th_percentile": 9869.02, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9597.55, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9597.55, "10th_percentile": 9597.55, "90th_percentile": 9597.55, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9053.88, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 9053.88, "10th_percentile": 9053.88, "90th_percentile": 9053.88, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 12003.25, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 12003.25, "10th_percentile": 12003.25, "90th_percentile": 12003.25, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $7,148.77; Total: $7,148.77", "median_amount": 7148.77, "10th_percentile": 7148.77, "90th_percentile": 7148.77, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $7,148.77; Total: $7,148.77" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $7,148.77; Total: $7,148.77", "median_amount": 7148.77, "10th_percentile": 7148.77, "90th_percentile": 7148.77, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $7,148.77; Total: $7,148.77" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $5,524.80; Total: $5,524.80 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5524.8, "10th_percentile": 5524.8, "90th_percentile": 5524.8, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $5,524.80; Total: $5,524.80 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $7,148.77; Percentage applied: 97.00%; Total: $6,934.31 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6934.31, "10th_percentile": 6934.31, "90th_percentile": 6934.31, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.772747725; Using historical claim(s); Scope: All Financial Classes; Cases: 9; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $7,148.77; Percentage applied: 97.00%; Total: $6,934.31 Paid at contractual rate, which is 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": "BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-190923", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "99991-0035-94", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.82, "maximum": 5.75, "setting": "outpatient", "gross_charge": 5.75, "discounted_cash": 4.02, "payers_information": [ { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "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": "CDH 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": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.19, "10th_percentile": 2.19, "90th_percentile": 2.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.19, "10th_percentile": 2.19, "90th_percentile": 2.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.19, "10th_percentile": 2.19, "90th_percentile": 2.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.19, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.19, "10th_percentile": 2.19, "90th_percentile": 2.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3.3, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3.3, "10th_percentile": 3.3, "90th_percentile": 3.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 2.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH 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": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 5.24, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 5.24, "10th_percentile": 5.24, "90th_percentile": 5.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 5.0, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4.42, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4.42, "10th_percentile": 4.42, "90th_percentile": 4.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.23, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 4.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 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": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 4.4, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% 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; 76.6% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 3.69, "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": 3.69, "10th_percentile": 3.69, "90th_percentile": 3.69, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2.37, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 3.85, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.85, "10th_percentile": 3.85, "90th_percentile": 3.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 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": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 2.89, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.89, "10th_percentile": 2.89, "90th_percentile": 2.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.15, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1.15, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3.31, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.31, "10th_percentile": 3.31, "90th_percentile": 3.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1.81, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1.81, "10th_percentile": 1.81, "90th_percentile": 1.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 3.04, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.04, "10th_percentile": 3.04, "90th_percentile": 3.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 2.01, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% 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; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.82, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 0.82, "10th_percentile": 0.82, "90th_percentile": 0.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1.73, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% 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 Other OP Services; 30% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.36, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.36, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2.36, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2.36, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2.58, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.58, "10th_percentile": 2.58, "90th_percentile": 2.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2.58, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.58, "10th_percentile": 2.58, "90th_percentile": 2.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH 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": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 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": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 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": "OP Default; 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 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; 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 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 Other Non-HL; 100% Billed" } ] } ] }, { "description": "BERN 5F 0.038INX125CM CATH PERI DIAG 1SD PORT", "code_information": [ { "code": "SUP-355795", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 107.8, "maximum": 753.86, "setting": "outpatient", "gross_charge": 753.86, "discounted_cash": 527.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 286.99, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.99, "10th_percentile": 286.99, "90th_percentile": 286.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 286.99, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.99, "10th_percentile": 286.99, "90th_percentile": 286.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 286.99, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.99, "10th_percentile": 286.99, "90th_percentile": 286.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 286.99, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.99, "10th_percentile": 286.99, "90th_percentile": 286.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 452.32, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 452.32, "10th_percentile": 452.32, "90th_percentile": 452.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 452.32, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 452.32, "10th_percentile": 452.32, "90th_percentile": 452.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 452.32, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 452.32, "10th_percentile": 452.32, "90th_percentile": 452.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 753.86, "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 $753.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "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 $753.86 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 753.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $753.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $753.86 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 753.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $753.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $753.86 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 753.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 753.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 753.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 753.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 236.71, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 236.71, "10th_percentile": 236.71, "90th_percentile": 236.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 434.22, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 434.22, "10th_percentile": 434.22, "90th_percentile": 434.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 107.8, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 107.8, "10th_percentile": 107.8, "90th_percentile": 107.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 226.16, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 226.16, "10th_percentile": 226.16, "90th_percentile": 226.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 263.85, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 263.85, "10th_percentile": 263.85, "90th_percentile": 263.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 398.04, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 398.04, "10th_percentile": 398.04, "90th_percentile": 398.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 309.31, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.31, "10th_percentile": 309.31, "90th_percentile": 309.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 309.31, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.31, "10th_percentile": 309.31, "90th_percentile": 309.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 150.77, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 150.77, "10th_percentile": 150.77, "90th_percentile": 150.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 150.77, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 150.77, "10th_percentile": 150.77, "90th_percentile": 150.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 309.69, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.69, "10th_percentile": 309.69, "90th_percentile": 309.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 309.69, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 309.69, "10th_percentile": 309.69, "90th_percentile": 309.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 338.18, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 338.18, "10th_percentile": 338.18, "90th_percentile": 338.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 338.18, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 338.18, "10th_percentile": 338.18, "90th_percentile": 338.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 452.32, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 452.32, "10th_percentile": 452.32, "90th_percentile": 452.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 504.33, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 504.33, "10th_percentile": 504.33, "90th_percentile": 504.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 378.44, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 378.44, "10th_percentile": 378.44, "90th_percentile": 378.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 687.52, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 687.52, "10th_percentile": 687.52, "90th_percentile": 687.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 484.2, "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": 484.2, "10th_percentile": 484.2, "90th_percentile": 484.2, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 311.34, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.34, "10th_percentile": 311.34, "90th_percentile": 311.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 603.09, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 603.09, "10th_percentile": 603.09, "90th_percentile": 603.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 376.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 376.93, "10th_percentile": 376.93, "90th_percentile": 376.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 161.33, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.33, "10th_percentile": 161.33, "90th_percentile": 161.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 432.72, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 432.72, "10th_percentile": 432.72, "90th_percentile": 432.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 655.86, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 655.86, "10th_percentile": 655.86, "90th_percentile": 655.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 474.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 474.93, "10th_percentile": 474.93, "90th_percentile": 474.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 579.72, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 579.72, "10th_percentile": 579.72, "90th_percentile": 579.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 577.46, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 577.46, "10th_percentile": 577.46, "90th_percentile": 577.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 603.09, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 603.09, "10th_percentile": 603.09, "90th_percentile": 603.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 376.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 376.93, "10th_percentile": 376.93, "90th_percentile": 376.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 753.86, "10th_percentile": 753.86, "90th_percentile": 753.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BEZLOTOXUMAB 25 MG/ML IV SOLN", "drug_information": { "unit": 40.0, "type": "ML" }, "code_information": [ { "code": "RX-211850", "type": "CDM" }, { "code": "J0565", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00006-3025-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 6718.82, "maximum": 97374.25, "setting": "outpatient", "gross_charge": 97374.25, "discounted_cash": 68161.97, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "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": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 3985.8, "10th_percentile": 3985.8, "90th_percentile": 3985.8, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 3985.8, "10th_percentile": 3985.8, "90th_percentile": 3985.8, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $97,374.25 @ 11.5% = $11,198.04 due to $0.00 Claim Price", "median_amount": 11198.04, "10th_percentile": 11198.04, "90th_percentile": 11198.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $97,374.25 @ 11.5% = $11,198.04 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $97,374.25 @ 11.5% = $11,198.04 due to $0.00 Claim Price", "median_amount": 11198.04, "10th_percentile": 11198.04, "90th_percentile": 11198.04, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $97,374.25 @ 11.5% = $11,198.04 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10808.54, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 10808.54, "10th_percentile": 10808.54, "90th_percentile": 10808.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10808.54, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 10808.54, "10th_percentile": 10808.54, "90th_percentile": 10808.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10808.54, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 10808.54, "10th_percentile": 10808.54, "90th_percentile": 10808.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10808.54, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 10808.54, "10th_percentile": 10808.54, "90th_percentile": 10808.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10808.54, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 10808.54, "10th_percentile": 10808.54, "90th_percentile": 10808.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10808.54, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 10808.54, "10th_percentile": 10808.54, "90th_percentile": 10808.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 58424.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 58424.55, "10th_percentile": 58424.55, "90th_percentile": 58424.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 58424.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 58424.55, "10th_percentile": 58424.55, "90th_percentile": 58424.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 58424.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 58424.55, "10th_percentile": 58424.55, "90th_percentile": 58424.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 6718.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6718.82, "10th_percentile": 6718.82, "90th_percentile": 6718.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 6718.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6718.82, "10th_percentile": 6718.82, "90th_percentile": 6718.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 6718.82, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6718.82, "10th_percentile": 6718.82, "90th_percentile": 6718.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 97374.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 97374.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 97374.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 97374.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $97,374.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $97,374.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 97374.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $97,374.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $97,374.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 97374.25, "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 $97,374.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "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 $97,374.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 97374.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 97374.25, "10th_percentile": 97374.25, "90th_percentile": 97374.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 40001.34, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40001.34, "10th_percentile": 40001.34, "90th_percentile": 40001.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 40001.34, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40001.34, "10th_percentile": 40001.34, "90th_percentile": 40001.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 17137.87, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17137.87, "10th_percentile": 17137.87, "90th_percentile": 17137.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 17137.87, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17137.87, "10th_percentile": 17137.87, "90th_percentile": 17137.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 13924.52, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 13924.52, "10th_percentile": 13924.52, "90th_percentile": 13924.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 34080.99, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 34080.99, "10th_percentile": 34080.99, "90th_percentile": 34080.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 29212.28, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 29212.28, "10th_percentile": 29212.28, "90th_percentile": 29212.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 30575.51, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 30575.51, "10th_percentile": 30575.51, "90th_percentile": 30575.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 58424.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 58424.55, "10th_percentile": 58424.55, "90th_percentile": 58424.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 48687.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48687.13, "10th_percentile": 48687.13, "90th_percentile": 48687.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 74880.8, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 74880.8, "10th_percentile": 74880.8, "90th_percentile": 74880.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 55892.82, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 55892.82, "10th_percentile": 55892.82, "90th_percentile": 55892.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 74588.68, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 74588.68, "10th_percentile": 74588.68, "90th_percentile": 74588.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 48687.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 48687.13, "10th_percentile": 48687.13, "90th_percentile": 48687.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 88805.32, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 88805.32, "10th_percentile": 88805.32, "90th_percentile": 88805.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 84715.6, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 84715.6, "10th_percentile": 84715.6, "90th_percentile": 84715.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 77899.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 77899.4, "10th_percentile": 77899.4, "90th_percentile": 77899.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 61345.78, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 61345.78, "10th_percentile": 61345.78, "90th_percentile": 61345.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 77899.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 77899.4, "10th_percentile": 77899.4, "90th_percentile": 77899.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" } ] } ] }, { "description": "BIOPATCH DRESSING (4150)", "code_information": [ { "code": "SUP-304467", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 18.21, "maximum": 127.31, "setting": "outpatient", "gross_charge": 127.31, "discounted_cash": 89.12, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 48.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.47, "10th_percentile": 48.47, "90th_percentile": 48.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 48.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.47, "10th_percentile": 48.47, "90th_percentile": 48.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 48.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.47, "10th_percentile": 48.47, "90th_percentile": 48.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 48.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.47, "10th_percentile": 48.47, "90th_percentile": 48.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 57.11, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.11, "10th_percentile": 57.11, "90th_percentile": 57.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 76.39, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 76.39, "10th_percentile": 76.39, "90th_percentile": 76.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 52.3, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.3, "10th_percentile": 52.3, "90th_percentile": 52.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 25.46, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 25.46, "10th_percentile": 25.46, "90th_percentile": 25.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 52.24, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.24, "10th_percentile": 52.24, "90th_percentile": 52.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 127.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $127.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $127.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 127.31, "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 $127.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "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 $127.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 127.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $127.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $127.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 127.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 76.39, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 76.39, "10th_percentile": 76.39, "90th_percentile": 76.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 76.39, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 76.39, "10th_percentile": 76.39, "90th_percentile": 76.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 38.19, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 38.19, "10th_percentile": 38.19, "90th_percentile": 38.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 44.56, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 44.56, "10th_percentile": 44.56, "90th_percentile": 44.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 73.33, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.33, "10th_percentile": 73.33, "90th_percentile": 73.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 18.21, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 18.21, "10th_percentile": 18.21, "90th_percentile": 18.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 67.22, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.22, "10th_percentile": 67.22, "90th_percentile": 67.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 39.98, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 39.98, "10th_percentile": 39.98, "90th_percentile": 39.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 127.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 127.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 127.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 52.24, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.24, "10th_percentile": 52.24, "90th_percentile": 52.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 52.3, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.3, "10th_percentile": 52.3, "90th_percentile": 52.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 25.46, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 25.46, "10th_percentile": 25.46, "90th_percentile": 25.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 85.17, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.17, "10th_percentile": 85.17, "90th_percentile": 85.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 63.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 63.66, "10th_percentile": 63.66, "90th_percentile": 63.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 63.91, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.91, "10th_percentile": 63.91, "90th_percentile": 63.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 73.08, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 73.08, "10th_percentile": 73.08, "90th_percentile": 73.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 97.52, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 97.52, "10th_percentile": 97.52, "90th_percentile": 97.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 57.11, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.11, "10th_percentile": 57.11, "90th_percentile": 57.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 80.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 80.21, "10th_percentile": 80.21, "90th_percentile": 80.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 27.24, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.24, "10th_percentile": 27.24, "90th_percentile": 27.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 101.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 101.85, "10th_percentile": 101.85, "90th_percentile": 101.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 52.58, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.58, "10th_percentile": 52.58, "90th_percentile": 52.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 101.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 101.85, "10th_percentile": 101.85, "90th_percentile": 101.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 81.77, "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": 81.77, "10th_percentile": 81.77, "90th_percentile": 81.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 76.39, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 76.39, "10th_percentile": 76.39, "90th_percentile": 76.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 116.11, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 116.11, "10th_percentile": 116.11, "90th_percentile": 116.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 110.76, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 110.76, "10th_percentile": 110.76, "90th_percentile": 110.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 97.9, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 97.9, "10th_percentile": 97.9, "90th_percentile": 97.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 63.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.66, "10th_percentile": 63.66, "90th_percentile": 63.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 127.31, "10th_percentile": 127.31, "90th_percentile": 127.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 13227.62, "maximum": 30904.21, "setting": "inpatient", "gross_charge": 133969.5, "discounted_cash": 93778.65, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 80381.7, "10th_percentile": 80381.7, "90th_percentile": 80381.7, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 80381.7, "10th_percentile": 80381.7, "90th_percentile": 80381.7, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 80381.7, "10th_percentile": 80381.7, "90th_percentile": 80381.7, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_percentage": 14.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 19157.67, "10th_percentile": 19157.67, "90th_percentile": 19157.67, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 66984.76, "10th_percentile": 66984.76, "90th_percentile": 66984.76, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 107175.6, "10th_percentile": 107175.6, "90th_percentile": 107175.6, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 66984.76, "10th_percentile": 66984.76, "90th_percentile": 66984.76, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_percentage": 87.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 116553.47, "10th_percentile": 116553.47, "90th_percentile": 116553.47, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_percentage": 58.4, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 78238.21, "10th_percentile": 78238.21, "90th_percentile": 78238.21, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; IP Services; 92% Billed", "median_amount": 123251.94, "10th_percentile": 123251.94, "90th_percentile": 123251.94, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_percentage": 92.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 92% Billed", "median_amount": 123251.94, "10th_percentile": 123251.94, "90th_percentile": 123251.94, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_percentage": 75.1, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All Inpatient Services; 75.1% Billed", "median_amount": 100611.09, "10th_percentile": 100611.09, "90th_percentile": 100611.09, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient Services; 63% Billed", "median_amount": 84400.79, "10th_percentile": 84400.79, "90th_percentile": 84400.79, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 29.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 29% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38851.16, "10th_percentile": 38851.16, "90th_percentile": 38851.16, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_percentage": 37.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All Inpatient Services; 37% Billed", "median_amount": 49568.72, "10th_percentile": 49568.72, "90th_percentile": 49568.72, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_percentage": 30.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 30% Billed", "median_amount": 40190.85, "10th_percentile": 40190.85, "90th_percentile": 40190.85, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_percentage": 32.6, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All Inpatient Services; 32.6% Billed", "median_amount": 43674.06, "10th_percentile": 43674.06, "90th_percentile": 43674.06, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services - OON; 100% Billed", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 133969.5, "10th_percentile": 133969.5, "90th_percentile": 133969.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 24710.36, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 24710.36, "10th_percentile": 24710.36, "90th_percentile": 24710.36, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 25409.3, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 25409.3, "10th_percentile": 25409.3, "90th_percentile": 25409.3, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 30904.21, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 182395.14, "10th_percentile": 182395.14, "90th_percentile": 182395.14, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 23310.61, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 23310.61, "10th_percentile": 23310.61, "90th_percentile": 23310.61, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 19676.46, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 19676.46, "10th_percentile": 19676.46, "90th_percentile": 19676.46, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 19676.46, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 10,585.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 19676.46, "10th_percentile": 19676.46, "90th_percentile": 19676.46, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 30904.21, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 16,625.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 182395.14, "10th_percentile": 182395.14, "90th_percentile": 182395.14, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 25409.3, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 13,669.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 25409.3, "10th_percentile": 25409.3, "90th_percentile": 25409.3, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 24710.36, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 13,293.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 24710.36, "10th_percentile": 24710.36, "90th_percentile": 24710.36, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 23310.61, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.8589, Rate: 12,540.00, and; Pricing Extension - NM HB XR PRC - CDH 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": 23310.61, "10th_percentile": 23310.61, "90th_percentile": 23310.61, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $14,224.45; Total: $14,224.45 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14224.45, "10th_percentile": 14224.45, "90th_percentile": 14224.45, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $14,224.45; Total: $14,224.45 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $15,959.54; Percentage applied: 97.00%; Total: $15,480.75 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15480.75, "10th_percentile": 15480.75, "90th_percentile": 15480.75, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME @97% & LESSO*; Note: Multiple pricing methods applied. Base payment: $15,959.54; Percentage applied: 97.00%; Total: $15,480.75 Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $15,959.54; Total: $15,959.54", "median_amount": 15959.54, "10th_percentile": 15959.54, "90th_percentile": 15959.54, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $15,959.54; Total: $15,959.54" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_dollar": 13227.62, "standard_charge_algorithm": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $15,959.54; Total: $15,959.54", "median_amount": 15959.54, "10th_percentile": 15959.54, "90th_percentile": 15959.54, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.802045539; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.86, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $15,959.54; Total: $15,959.54" } ] } ] }, { "description": "BIOPSY PUNCH ACUDERM 2.0MM", "code_information": [ { "code": "SUP-9041766", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 14.19, "maximum": 99.22, "setting": "outpatient", "gross_charge": 99.22, "discounted_cash": 69.45, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 37.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.77, "10th_percentile": 37.77, "90th_percentile": 37.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 37.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.77, "10th_percentile": 37.77, "90th_percentile": 37.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 29.77, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 29.77, "10th_percentile": 29.77, "90th_percentile": 29.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 34.73, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 34.73, "10th_percentile": 34.73, "90th_percentile": 34.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 57.15, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.15, "10th_percentile": 57.15, "90th_percentile": 57.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 14.19, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 14.19, "10th_percentile": 14.19, "90th_percentile": 14.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 52.39, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.39, "10th_percentile": 52.39, "90th_percentile": 52.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 31.16, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 31.16, "10th_percentile": 31.16, "90th_percentile": 31.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 40.71, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.71, "10th_percentile": 40.71, "90th_percentile": 40.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 40.76, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 44.51, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.51, "10th_percentile": 44.51, "90th_percentile": 44.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "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": "CDH ADVOCATE IPA", "standard_charge_dollar": 59.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 59.53, "10th_percentile": 59.53, "90th_percentile": 59.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 44.51, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.51, "10th_percentile": 44.51, "90th_percentile": 44.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 40.76, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 19.84, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 19.84, "10th_percentile": 19.84, "90th_percentile": 19.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 40.71, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.71, "10th_percentile": 40.71, "90th_percentile": 40.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 99.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $99.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $99.22 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 99.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $99.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $99.22 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 99.22, "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 $99.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "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 $99.22 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 99.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 37.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.77, "10th_percentile": 37.77, "90th_percentile": 37.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 37.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.77, "10th_percentile": 37.77, "90th_percentile": 37.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 99.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 99.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 99.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 49.81, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.81, "10th_percentile": 49.81, "90th_percentile": 49.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 76.3, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 76.3, "10th_percentile": 76.3, "90th_percentile": 76.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 63.73, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 63.73, "10th_percentile": 63.73, "90th_percentile": 63.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 66.38, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.38, "10th_percentile": 66.38, "90th_percentile": 66.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 90.49, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 90.49, "10th_percentile": 90.49, "90th_percentile": 90.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 79.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 79.38, "10th_percentile": 79.38, "90th_percentile": 79.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 56.95, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 56.95, "10th_percentile": 56.95, "90th_percentile": 56.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 59.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 59.53, "10th_percentile": 59.53, "90th_percentile": 59.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 49.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.61, "10th_percentile": 49.61, "90th_percentile": 49.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 79.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 79.38, "10th_percentile": 79.38, "90th_percentile": 79.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 19.84, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 19.84, "10th_percentile": 19.84, "90th_percentile": 19.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 21.23, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.23, "10th_percentile": 21.23, "90th_percentile": 21.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 86.32, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 86.32, "10th_percentile": 86.32, "90th_percentile": 86.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 40.98, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.98, "10th_percentile": 40.98, "90th_percentile": 40.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 76.0, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 76.0, "10th_percentile": 76.0, "90th_percentile": 76.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 49.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 49.61, "10th_percentile": 49.61, "90th_percentile": 49.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 62.51, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 62.51, "10th_percentile": 62.51, "90th_percentile": 62.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 59.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 59.53, "10th_percentile": 59.53, "90th_percentile": 59.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 59.53, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 59.53, "10th_percentile": 59.53, "90th_percentile": 59.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 99.22, "10th_percentile": 99.22, "90th_percentile": 99.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BISACODYL 10 MG RECT SUPP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-1080", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00574-7050-50", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.16, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1.72, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1.72, "10th_percentile": 1.72, "90th_percentile": 1.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1.73, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% 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; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 0.4, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.4, "10th_percentile": 0.4, "90th_percentile": 0.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 0.4, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.4, "10th_percentile": 0.4, "90th_percentile": 0.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.32, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 0.79, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 0.79, "10th_percentile": 0.79, "90th_percentile": 0.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 0.68, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% 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 Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1.3, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 0.71, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1.19, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 0.45, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 0.92, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 0.92, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.25 @ 11.5% = $0.26 due to $0.00 Claim Price", "median_amount": 0.26, "10th_percentile": 0.26, "90th_percentile": 0.26, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.25 @ 11.5% = $0.26 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1.29, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1.29, "10th_percentile": 1.29, "90th_percentile": 1.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1.96, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1.96, "10th_percentile": 1.96, "90th_percentile": 1.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1.51, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 1.45, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 2.05, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2.05, "10th_percentile": 2.05, "90th_percentile": 2.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1.42, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 0.45, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 0.16, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.16, "10th_percentile": 0.16, "90th_percentile": 0.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.25 @ 11.5% = $0.26 due to $0.00 Claim Price", "median_amount": 0.26, "10th_percentile": 0.26, "90th_percentile": 0.26, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $2.25 @ 11.5% = $0.26 due to $0.00 Claim Price" } ] } ] }, { "description": "BIT DRILL 135MM 2.7 VOLT ADD ON QUICK CONNECT CALIBRATION", "code_information": [ { "code": "SUP-451156", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 383.05, "maximum": 2678.64, "setting": "outpatient", "gross_charge": 2678.64, "discounted_cash": 1875.05, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1019.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.76, "10th_percentile": 1019.76, "90th_percentile": 1019.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1019.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.76, "10th_percentile": 1019.76, "90th_percentile": 1019.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1019.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.76, "10th_percentile": 1019.76, "90th_percentile": 1019.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1019.76, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1019.76, "10th_percentile": 1019.76, "90th_percentile": 1019.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1201.64, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1201.64, "10th_percentile": 1201.64, "90th_percentile": 1201.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1607.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1607.18, "10th_percentile": 1607.18, "90th_percentile": 1607.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1100.39, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1100.39, "10th_percentile": 1100.39, "90th_percentile": 1100.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 535.73, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 535.73, "10th_percentile": 535.73, "90th_percentile": 535.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1099.05, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1099.05, "10th_percentile": 1099.05, "90th_percentile": 1099.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2678.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,678.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,678.64 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2678.64, "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 $2,678.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "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 $2,678.64 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2678.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,678.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,678.64 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2678.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1607.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1607.18, "10th_percentile": 1607.18, "90th_percentile": 1607.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1607.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1607.18, "10th_percentile": 1607.18, "90th_percentile": 1607.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 803.59, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 803.59, "10th_percentile": 803.59, "90th_percentile": 803.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 937.52, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 937.52, "10th_percentile": 937.52, "90th_percentile": 937.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1542.9, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1542.9, "10th_percentile": 1542.9, "90th_percentile": 1542.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 383.05, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 383.05, "10th_percentile": 383.05, "90th_percentile": 383.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1414.32, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1414.32, "10th_percentile": 1414.32, "90th_percentile": 1414.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 841.09, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 841.09, "10th_percentile": 841.09, "90th_percentile": 841.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2678.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2678.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2678.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1099.05, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1099.05, "10th_percentile": 1099.05, "90th_percentile": 1099.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1100.39, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1100.39, "10th_percentile": 1100.39, "90th_percentile": 1100.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 535.73, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 535.73, "10th_percentile": 535.73, "90th_percentile": 535.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1792.01, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1792.01, "10th_percentile": 1792.01, "90th_percentile": 1792.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1339.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1339.32, "10th_percentile": 1339.32, "90th_percentile": 1339.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1344.68, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1344.68, "10th_percentile": 1344.68, "90th_percentile": 1344.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1537.54, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1537.54, "10th_percentile": 1537.54, "90th_percentile": 1537.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2051.84, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2051.84, "10th_percentile": 2051.84, "90th_percentile": 2051.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1201.64, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1201.64, "10th_percentile": 1201.64, "90th_percentile": 1201.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1687.54, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1687.54, "10th_percentile": 1687.54, "90th_percentile": 1687.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 573.23, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 573.23, "10th_percentile": 573.23, "90th_percentile": 573.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2142.91, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2142.91, "10th_percentile": 2142.91, "90th_percentile": 2142.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1106.28, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1106.28, "10th_percentile": 1106.28, "90th_percentile": 1106.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2142.91, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2142.91, "10th_percentile": 2142.91, "90th_percentile": 2142.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1720.49, "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": 1720.49, "10th_percentile": 1720.49, "90th_percentile": 1720.49, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1607.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1607.18, "10th_percentile": 1607.18, "90th_percentile": 1607.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 2442.92, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2442.92, "10th_percentile": 2442.92, "90th_percentile": 2442.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2330.42, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2330.42, "10th_percentile": 2330.42, "90th_percentile": 2330.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2059.87, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2059.87, "10th_percentile": 2059.87, "90th_percentile": 2059.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1339.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1339.32, "10th_percentile": 1339.32, "90th_percentile": 1339.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2678.64, "10th_percentile": 2678.64, "90th_percentile": 2678.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 13MM TI ALLOY ACP SPINAL PLATE 7786713", "code_information": [ { "code": "SUP-377525", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 271.42, "maximum": 1898.05, "setting": "outpatient", "gross_charge": 1898.05, "discounted_cash": 1328.63, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 851.47, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 851.47, "10th_percentile": 851.47, "90th_percentile": 851.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 779.72, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.72, "10th_percentile": 779.72, "90th_percentile": 779.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 379.61, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 379.61, "10th_percentile": 379.61, "90th_percentile": 379.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 778.77, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.77, "10th_percentile": 778.77, "90th_percentile": 778.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1898.05, "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 $1,898.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "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 $1,898.05 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1002.17, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1002.17, "10th_percentile": 1002.17, "90th_percentile": 1002.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1093.28, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1093.28, "10th_percentile": 1093.28, "90th_percentile": 1093.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 595.99, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 595.99, "10th_percentile": 595.99, "90th_percentile": 595.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 569.42, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 569.42, "10th_percentile": 569.42, "90th_percentile": 569.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 271.42, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 271.42, "10th_percentile": 271.42, "90th_percentile": 271.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 664.32, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 664.32, "10th_percentile": 664.32, "90th_percentile": 664.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 952.82, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.82, "10th_percentile": 952.82, "90th_percentile": 952.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1459.6, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1459.6, "10th_percentile": 1459.6, "90th_percentile": 1459.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1219.12, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1219.12, "10th_percentile": 1219.12, "90th_percentile": 1219.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH UHC HMO/PPO", "standard_charge_dollar": 1269.8, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1269.8, "10th_percentile": 1269.8, "90th_percentile": 1269.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 1731.02, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1731.02, "10th_percentile": 1731.02, "90th_percentile": 1731.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1518.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1518.44, "10th_percentile": 1518.44, "90th_percentile": 1518.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 779.72, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.72, "10th_percentile": 779.72, "90th_percentile": 779.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1089.48, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1089.48, "10th_percentile": 1089.48, "90th_percentile": 1089.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 949.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.03, "10th_percentile": 949.03, "90th_percentile": 949.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1518.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1518.44, "10th_percentile": 1518.44, "90th_percentile": 1518.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 778.77, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.77, "10th_percentile": 778.77, "90th_percentile": 778.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 379.61, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 379.61, "10th_percentile": 379.61, "90th_percentile": 379.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 406.18, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 406.18, "10th_percentile": 406.18, "90th_percentile": 406.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1651.3, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1651.3, "10th_percentile": 1651.3, "90th_percentile": 1651.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 783.89, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 783.89, "10th_percentile": 783.89, "90th_percentile": 783.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 1453.91, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1453.91, "10th_percentile": 1453.91, "90th_percentile": 1453.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 949.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 949.03, "10th_percentile": 949.03, "90th_percentile": 949.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1195.77, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1195.77, "10th_percentile": 1195.77, "90th_percentile": 1195.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 851.47, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 851.47, "10th_percentile": 851.47, "90th_percentile": 851.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 2.45MM 10DEG ANGLED NONCANN INSERTION PHALINX 45303145", "code_information": [ { "code": "SUP-316172", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 430.03, "maximum": 3007.18, "setting": "outpatient", "gross_charge": 3007.18, "discounted_cash": 2105.03, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1804.31, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1804.31, "10th_percentile": 1804.31, "90th_percentile": 1804.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1349.02, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1349.02, "10th_percentile": 1349.02, "90th_percentile": 1349.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1235.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1235.35, "10th_percentile": 1235.35, "90th_percentile": 1235.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 601.44, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 601.44, "10th_percentile": 601.44, "90th_percentile": 601.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1233.85, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1233.85, "10th_percentile": 1233.85, "90th_percentile": 1233.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3007.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,007.18 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,007.18 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3007.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,007.18 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,007.18 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3007.18, "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 $3,007.18 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "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 $3,007.18 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3007.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1144.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1144.83, "10th_percentile": 1144.83, "90th_percentile": 1144.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1144.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1144.83, "10th_percentile": 1144.83, "90th_percentile": 1144.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1587.79, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1587.79, "10th_percentile": 1587.79, "90th_percentile": 1587.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1732.14, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1732.14, "10th_percentile": 1732.14, "90th_percentile": 1732.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 944.25, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 944.25, "10th_percentile": 944.25, "90th_percentile": 944.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 902.15, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 902.15, "10th_percentile": 902.15, "90th_percentile": 902.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 430.03, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 430.03, "10th_percentile": 430.03, "90th_percentile": 430.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1052.51, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1052.51, "10th_percentile": 1052.51, "90th_percentile": 1052.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2312.52, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2312.52, "10th_percentile": 2312.52, "90th_percentile": 2312.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2405.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2405.74, "10th_percentile": 2405.74, "90th_percentile": 2405.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1235.35, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1235.35, "10th_percentile": 1235.35, "90th_percentile": 1235.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1503.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1503.59, "10th_percentile": 1503.59, "90th_percentile": 1503.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2405.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2405.74, "10th_percentile": 2405.74, "90th_percentile": 2405.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1233.85, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1233.85, "10th_percentile": 1233.85, "90th_percentile": 1233.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 643.54, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 643.54, "10th_percentile": 643.54, "90th_percentile": 643.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1241.97, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1241.97, "10th_percentile": 1241.97, "90th_percentile": 1241.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2303.5, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2303.5, "10th_percentile": 2303.5, "90th_percentile": 2303.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1349.02, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1349.02, "10th_percentile": 1349.02, "90th_percentile": 1349.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1804.31, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1804.31, "10th_percentile": 1804.31, "90th_percentile": 1804.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1144.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1144.83, "10th_percentile": 1144.83, "90th_percentile": 1144.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1144.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1144.83, "10th_percentile": 1144.83, "90th_percentile": 1144.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1804.31, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1804.31, "10th_percentile": 1804.31, "90th_percentile": 1804.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3007.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3007.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3007.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 601.44, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 601.44, "10th_percentile": 601.44, "90th_percentile": 601.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2011.8, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2011.8, "10th_percentile": 2011.8, "90th_percentile": 2011.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1503.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1503.59, "10th_percentile": 1503.59, "90th_percentile": 1503.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1509.6, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1509.6, "10th_percentile": 1509.6, "90th_percentile": 1509.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1726.12, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1726.12, "10th_percentile": 1726.12, "90th_percentile": 1726.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1894.52, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1894.52, "10th_percentile": 1894.52, "90th_percentile": 1894.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1931.51, "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": 1931.51, "10th_percentile": 1931.51, "90th_percentile": 1931.51, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1804.31, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1804.31, "10th_percentile": 1804.31, "90th_percentile": 1804.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 2742.55, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2742.55, "10th_percentile": 2742.55, "90th_percentile": 2742.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2616.25, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2616.25, "10th_percentile": 2616.25, "90th_percentile": 2616.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3007.18, "10th_percentile": 3007.18, "90th_percentile": 3007.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL 60X145MM 1.8 VOLT", "code_information": [ { "code": "SUP-450989", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 439.63, "maximum": 3074.32, "setting": "outpatient", "gross_charge": 3074.32, "discounted_cash": 2152.02, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1170.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1170.39, "10th_percentile": 1170.39, "90th_percentile": 1170.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1170.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1170.39, "10th_percentile": 1170.39, "90th_percentile": 1170.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1170.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1170.39, "10th_percentile": 1170.39, "90th_percentile": 1170.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1170.39, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1170.39, "10th_percentile": 1170.39, "90th_percentile": 1170.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1379.14, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1379.14, "10th_percentile": 1379.14, "90th_percentile": 1379.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1844.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1844.59, "10th_percentile": 1844.59, "90th_percentile": 1844.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1262.93, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1262.93, "10th_percentile": 1262.93, "90th_percentile": 1262.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 614.86, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 614.86, "10th_percentile": 614.86, "90th_percentile": 614.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1261.39, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1261.39, "10th_percentile": 1261.39, "90th_percentile": 1261.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,074.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,074.32 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,074.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,074.32 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,074.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,074.32 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1844.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1844.59, "10th_percentile": 1844.59, "90th_percentile": 1844.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 922.3, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 922.3, "10th_percentile": 922.3, "90th_percentile": 922.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1076.01, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1076.01, "10th_percentile": 1076.01, "90th_percentile": 1076.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1770.81, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1770.81, "10th_percentile": 1770.81, "90th_percentile": 1770.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 439.63, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 439.63, "10th_percentile": 439.63, "90th_percentile": 439.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1623.24, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1623.24, "10th_percentile": 1623.24, "90th_percentile": 1623.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 965.34, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 965.34, "10th_percentile": 965.34, "90th_percentile": 965.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1261.39, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1261.39, "10th_percentile": 1261.39, "90th_percentile": 1261.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1262.93, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1262.93, "10th_percentile": 1262.93, "90th_percentile": 1262.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2354.93, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2354.93, "10th_percentile": 2354.93, "90th_percentile": 2354.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1379.14, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1379.14, "10th_percentile": 1379.14, "90th_percentile": 1379.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 657.9, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 657.9, "10th_percentile": 657.9, "90th_percentile": 657.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2459.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2459.46, "10th_percentile": 2459.46, "90th_percentile": 2459.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1269.69, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1269.69, "10th_percentile": 1269.69, "90th_percentile": 1269.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2459.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2459.46, "10th_percentile": 2459.46, "90th_percentile": 2459.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 2803.78, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2803.78, "10th_percentile": 2803.78, "90th_percentile": 2803.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2364.15, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2364.15, "10th_percentile": 2364.15, "90th_percentile": 2364.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1537.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1537.16, "10th_percentile": 1537.16, "90th_percentile": 1537.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1844.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1844.59, "10th_percentile": 1844.59, "90th_percentile": 1844.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3074.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 614.86, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 614.86, "10th_percentile": 614.86, "90th_percentile": 614.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1844.59, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1844.59, "10th_percentile": 1844.59, "90th_percentile": 1844.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2056.72, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2056.72, "10th_percentile": 2056.72, "90th_percentile": 2056.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1543.31, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1543.31, "10th_percentile": 1543.31, "90th_percentile": 1543.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 1974.64, "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": 1974.64, "10th_percentile": 1974.64, "90th_percentile": 1974.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1537.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1537.16, "10th_percentile": 1537.16, "90th_percentile": 1537.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1764.66, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1764.66, "10th_percentile": 1764.66, "90th_percentile": 1764.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2674.66, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2674.66, "10th_percentile": 2674.66, "90th_percentile": 2674.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1936.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1936.82, "10th_percentile": 1936.82, "90th_percentile": 1936.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3074.32, "10th_percentile": 3074.32, "90th_percentile": 3074.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL SPS 12MM STERILE", "code_information": [ { "code": "SUP-452145", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 271.42, "maximum": 1898.05, "setting": "outpatient", "gross_charge": 1898.05, "discounted_cash": 1328.63, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 722.59, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 722.59, "10th_percentile": 722.59, "90th_percentile": 722.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 851.47, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 851.47, "10th_percentile": 851.47, "90th_percentile": 851.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 779.72, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.72, "10th_percentile": 779.72, "90th_percentile": 779.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 379.61, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 379.61, "10th_percentile": 379.61, "90th_percentile": 379.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 778.77, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.77, "10th_percentile": 778.77, "90th_percentile": 778.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1898.05, "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 $1,898.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "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 $1,898.05 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,898.05 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 569.42, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 569.42, "10th_percentile": 569.42, "90th_percentile": 569.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 664.32, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 664.32, "10th_percentile": 664.32, "90th_percentile": 664.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1093.28, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1093.28, "10th_percentile": 1093.28, "90th_percentile": 1093.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 271.42, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 271.42, "10th_percentile": 271.42, "90th_percentile": 271.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1002.17, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1002.17, "10th_percentile": 1002.17, "90th_percentile": 1002.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 595.99, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 595.99, "10th_percentile": 595.99, "90th_percentile": 595.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1898.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 778.77, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.77, "10th_percentile": 778.77, "90th_percentile": 778.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 779.72, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.72, "10th_percentile": 779.72, "90th_percentile": 779.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 379.61, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 379.61, "10th_percentile": 379.61, "90th_percentile": 379.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1269.8, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1269.8, "10th_percentile": 1269.8, "90th_percentile": 1269.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 949.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 949.03, "10th_percentile": 949.03, "90th_percentile": 949.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 952.82, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.82, "10th_percentile": 952.82, "90th_percentile": 952.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1089.48, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1089.48, "10th_percentile": 1089.48, "90th_percentile": 1089.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 1453.91, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 1453.91, "10th_percentile": 1453.91, "90th_percentile": 1453.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 851.47, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 851.47, "10th_percentile": 851.47, "90th_percentile": 851.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1195.77, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1195.77, "10th_percentile": 1195.77, "90th_percentile": 1195.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 406.18, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 406.18, "10th_percentile": 406.18, "90th_percentile": 406.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 1518.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 1518.44, "10th_percentile": 1518.44, "90th_percentile": 1518.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 783.89, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 783.89, "10th_percentile": 783.89, "90th_percentile": 783.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1518.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 1518.44, "10th_percentile": 1518.44, "90th_percentile": 1518.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1219.12, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1219.12, "10th_percentile": 1219.12, "90th_percentile": 1219.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1138.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1138.83, "10th_percentile": 1138.83, "90th_percentile": 1138.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1731.02, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1731.02, "10th_percentile": 1731.02, "90th_percentile": 1731.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 1651.3, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 1651.3, "10th_percentile": 1651.3, "90th_percentile": 1651.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 1459.6, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 1459.6, "10th_percentile": 1459.6, "90th_percentile": 1459.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 949.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.03, "10th_percentile": 949.03, "90th_percentile": 949.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1898.05, "10th_percentile": 1898.05, "90th_percentile": 1898.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRILL ZIM 5/64\"", "code_information": [ { "code": "SUP-309215", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 84.77, "maximum": 592.77, "setting": "outpatient", "gross_charge": 592.77, "discounted_cash": 414.94, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 225.67, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.67, "10th_percentile": 225.67, "90th_percentile": 225.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 225.67, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.67, "10th_percentile": 225.67, "90th_percentile": 225.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 225.67, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.67, "10th_percentile": 225.67, "90th_percentile": 225.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 225.67, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.67, "10th_percentile": 225.67, "90th_percentile": 225.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 265.92, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.92, "10th_percentile": 265.92, "90th_percentile": 265.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 355.66, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 355.66, "10th_percentile": 355.66, "90th_percentile": 355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 243.51, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.51, "10th_percentile": 243.51, "90th_percentile": 243.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 118.55, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 118.55, "10th_percentile": 118.55, "90th_percentile": 118.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 243.21, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.21, "10th_percentile": 243.21, "90th_percentile": 243.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 592.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $592.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $592.77 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 592.77, "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 $592.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "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 $592.77 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 592.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $592.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $592.77 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 592.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 355.66, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 355.66, "10th_percentile": 355.66, "90th_percentile": 355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 355.66, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 355.66, "10th_percentile": 355.66, "90th_percentile": 355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 177.83, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 177.83, "10th_percentile": 177.83, "90th_percentile": 177.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 207.47, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 207.47, "10th_percentile": 207.47, "90th_percentile": 207.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 341.44, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 341.44, "10th_percentile": 341.44, "90th_percentile": 341.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 84.77, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 84.77, "10th_percentile": 84.77, "90th_percentile": 84.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 312.98, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 312.98, "10th_percentile": 312.98, "90th_percentile": 312.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 186.13, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 186.13, "10th_percentile": 186.13, "90th_percentile": 186.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 592.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 592.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 592.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 243.21, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.21, "10th_percentile": 243.21, "90th_percentile": 243.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 243.51, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.51, "10th_percentile": 243.51, "90th_percentile": 243.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 118.55, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 118.55, "10th_percentile": 118.55, "90th_percentile": 118.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 396.56, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.56, "10th_percentile": 396.56, "90th_percentile": 396.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 296.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 296.39, "10th_percentile": 296.39, "90th_percentile": 296.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 297.57, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 297.57, "10th_percentile": 297.57, "90th_percentile": 297.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 340.25, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 340.25, "10th_percentile": 340.25, "90th_percentile": 340.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 454.06, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 454.06, "10th_percentile": 454.06, "90th_percentile": 454.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 265.92, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.92, "10th_percentile": 265.92, "90th_percentile": 265.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 373.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 373.45, "10th_percentile": 373.45, "90th_percentile": 373.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 126.85, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.85, "10th_percentile": 126.85, "90th_percentile": 126.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 474.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 474.22, "10th_percentile": 474.22, "90th_percentile": 474.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 244.81, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.81, "10th_percentile": 244.81, "90th_percentile": 244.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 474.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 474.22, "10th_percentile": 474.22, "90th_percentile": 474.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 380.74, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 380.74, "10th_percentile": 380.74, "90th_percentile": 380.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 355.66, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 355.66, "10th_percentile": 355.66, "90th_percentile": 355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 540.61, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 540.61, "10th_percentile": 540.61, "90th_percentile": 540.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 515.71, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 515.71, "10th_percentile": 515.71, "90th_percentile": 515.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 455.84, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 455.84, "10th_percentile": 455.84, "90th_percentile": 455.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 296.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 296.39, "10th_percentile": 296.39, "90th_percentile": 296.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 592.77, "10th_percentile": 592.77, "90th_percentile": 592.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRLL 135X45MM QC CLBRTN STRL", "code_information": [ { "code": "SUP-432981", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 378.81, "maximum": 2649.0, "setting": "outpatient", "gross_charge": 2649.0, "discounted_cash": 1854.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1008.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.47, "10th_percentile": 1008.47, "90th_percentile": 1008.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1008.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.47, "10th_percentile": 1008.47, "90th_percentile": 1008.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1008.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.47, "10th_percentile": 1008.47, "90th_percentile": 1008.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1008.47, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1008.47, "10th_percentile": 1008.47, "90th_percentile": 1008.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1589.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1589.4, "10th_percentile": 1589.4, "90th_percentile": 1589.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1589.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1589.4, "10th_percentile": 1589.4, "90th_percentile": 1589.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1589.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1589.4, "10th_percentile": 1589.4, "90th_percentile": 1589.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2649.0, "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 $2,649.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "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 $2,649.00 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 2649.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,649.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,649.00 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 2649.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,649.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,649.00 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 2649.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2649.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 2649.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2649.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 831.79, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 831.79, "10th_percentile": 831.79, "90th_percentile": 831.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1525.82, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1525.82, "10th_percentile": 1525.82, "90th_percentile": 1525.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 378.81, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 378.81, "10th_percentile": 378.81, "90th_percentile": 378.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 794.7, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 794.7, "10th_percentile": 794.7, "90th_percentile": 794.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 927.15, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 927.15, "10th_percentile": 927.15, "90th_percentile": 927.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1398.67, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1398.67, "10th_percentile": 1398.67, "90th_percentile": 1398.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1086.88, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1086.88, "10th_percentile": 1086.88, "90th_percentile": 1086.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1086.88, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1086.88, "10th_percentile": 1086.88, "90th_percentile": 1086.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 529.8, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 529.8, "10th_percentile": 529.8, "90th_percentile": 529.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 529.8, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 529.8, "10th_percentile": 529.8, "90th_percentile": 529.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1088.21, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1088.21, "10th_percentile": 1088.21, "90th_percentile": 1088.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1088.21, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1088.21, "10th_percentile": 1088.21, "90th_percentile": 1088.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1188.34, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.34, "10th_percentile": 1188.34, "90th_percentile": 1188.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1188.34, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.34, "10th_percentile": 1188.34, "90th_percentile": 1188.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1589.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1589.4, "10th_percentile": 1589.4, "90th_percentile": 1589.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 1772.18, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1772.18, "10th_percentile": 1772.18, "90th_percentile": 1772.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1329.8, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1329.8, "10th_percentile": 1329.8, "90th_percentile": 1329.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 2415.89, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2415.89, "10th_percentile": 2415.89, "90th_percentile": 2415.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 1701.45, "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": 1701.45, "10th_percentile": 1701.45, "90th_percentile": 1701.45, "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": "CDH CIGNA BROAD", "standard_charge_dollar": 1094.04, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1094.04, "10th_percentile": 1094.04, "90th_percentile": 1094.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2119.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2119.2, "10th_percentile": 2119.2, "90th_percentile": 2119.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1324.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1324.5, "10th_percentile": 1324.5, "90th_percentile": 1324.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 566.89, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 566.89, "10th_percentile": 566.89, "90th_percentile": 566.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1520.53, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1520.53, "10th_percentile": 1520.53, "90th_percentile": 1520.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2304.63, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2304.63, "10th_percentile": 2304.63, "90th_percentile": 2304.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1668.87, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1668.87, "10th_percentile": 1668.87, "90th_percentile": 1668.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2037.08, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2037.08, "10th_percentile": 2037.08, "90th_percentile": 2037.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 2029.13, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2029.13, "10th_percentile": 2029.13, "90th_percentile": 2029.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2119.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2119.2, "10th_percentile": 2119.2, "90th_percentile": 2119.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1324.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1324.5, "10th_percentile": 1324.5, "90th_percentile": 1324.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2649.0, "10th_percentile": 2649.0, "90th_percentile": 2649.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRLL 195X6MM CNNLTD QCK CPLNG ADJSTBL STP RSBL", "code_information": [ { "code": "SUP-438947", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 469.44, "maximum": 3282.83, "setting": "outpatient", "gross_charge": 3282.83, "discounted_cash": 2297.98, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1249.77, "10th_percentile": 1249.77, "90th_percentile": 1249.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1249.77, "10th_percentile": 1249.77, "90th_percentile": 1249.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1249.77, "10th_percentile": 1249.77, "90th_percentile": 1249.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1249.77, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1249.77, "10th_percentile": 1249.77, "90th_percentile": 1249.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1472.68, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1472.68, "10th_percentile": 1472.68, "90th_percentile": 1472.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1969.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1969.7, "10th_percentile": 1969.7, "90th_percentile": 1969.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1348.59, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1348.59, "10th_percentile": 1348.59, "90th_percentile": 1348.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 656.57, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 656.57, "10th_percentile": 656.57, "90th_percentile": 656.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1346.95, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1346.95, "10th_percentile": 1346.95, "90th_percentile": 1346.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,282.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,282.83 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,282.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,282.83 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,282.83 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,282.83 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 984.85, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 984.85, "10th_percentile": 984.85, "90th_percentile": 984.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1148.99, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1148.99, "10th_percentile": 1148.99, "90th_percentile": 1148.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1890.91, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1890.91, "10th_percentile": 1890.91, "90th_percentile": 1890.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 469.44, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 469.44, "10th_percentile": 469.44, "90th_percentile": 469.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1733.33, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1733.33, "10th_percentile": 1733.33, "90th_percentile": 1733.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1030.81, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1030.81, "10th_percentile": 1030.81, "90th_percentile": 1030.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1346.95, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1346.95, "10th_percentile": 1346.95, "90th_percentile": 1346.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1348.59, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1348.59, "10th_percentile": 1348.59, "90th_percentile": 1348.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1472.68, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1472.68, "10th_percentile": 1472.68, "90th_percentile": 1472.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3282.83, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1647.98, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1647.98, "10th_percentile": 1647.98, "90th_percentile": 1647.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2524.5, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2524.5, "10th_percentile": 2524.5, "90th_percentile": 2524.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2108.56, "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": 2108.56, "10th_percentile": 2108.56, "90th_percentile": 2108.56, "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": "CDH UHC HMO/PPO", "standard_charge_dollar": 2196.21, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2196.21, "10th_percentile": 2196.21, "90th_percentile": 2196.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 2993.94, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2993.94, "10th_percentile": 2993.94, "90th_percentile": 2993.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2626.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2626.26, "10th_percentile": 2626.26, "90th_percentile": 2626.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1884.34, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1884.34, "10th_percentile": 1884.34, "90th_percentile": 1884.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1969.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1969.7, "10th_percentile": 1969.7, "90th_percentile": 1969.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1641.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1641.42, "10th_percentile": 1641.42, "90th_percentile": 1641.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2626.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2626.26, "10th_percentile": 2626.26, "90th_percentile": 2626.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 656.57, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 656.57, "10th_percentile": 656.57, "90th_percentile": 656.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 702.53, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 702.53, "10th_percentile": 702.53, "90th_percentile": 702.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2856.06, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2856.06, "10th_percentile": 2856.06, "90th_percentile": 2856.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1355.81, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1355.81, "10th_percentile": 1355.81, "90th_percentile": 1355.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2514.65, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2514.65, "10th_percentile": 2514.65, "90th_percentile": 2514.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1641.42, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1641.42, "10th_percentile": 1641.42, "90th_percentile": 1641.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2068.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2068.18, "10th_percentile": 2068.18, "90th_percentile": 2068.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1969.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1969.7, "10th_percentile": 1969.7, "90th_percentile": 1969.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1969.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1969.7, "10th_percentile": 1969.7, "90th_percentile": 1969.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3282.83, "10th_percentile": 3282.83, "90th_percentile": 3282.83, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIT DRLL 215X5MM CNNLTD LG QCK CPLNG STRL", "code_information": [ { "code": "SUP-433849", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 774.64, "maximum": 5417.06, "setting": "outpatient", "gross_charge": 5417.06, "discounted_cash": 3791.94, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2062.27, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2062.27, "10th_percentile": 2062.27, "90th_percentile": 2062.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2062.27, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2062.27, "10th_percentile": 2062.27, "90th_percentile": 2062.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2062.27, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2062.27, "10th_percentile": 2062.27, "90th_percentile": 2062.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2062.27, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2062.27, "10th_percentile": 2062.27, "90th_percentile": 2062.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2430.09, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2430.09, "10th_percentile": 2430.09, "90th_percentile": 2430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3250.24, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3250.24, "10th_percentile": 3250.24, "90th_percentile": 3250.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2225.33, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2225.33, "10th_percentile": 2225.33, "90th_percentile": 2225.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1083.41, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1083.41, "10th_percentile": 1083.41, "90th_percentile": 1083.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2222.62, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2222.62, "10th_percentile": 2222.62, "90th_percentile": 2222.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 5417.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,417.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,417.06 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5417.06, "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 $5,417.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "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 $5,417.06 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 5417.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,417.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,417.06 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 5417.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3250.24, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3250.24, "10th_percentile": 3250.24, "90th_percentile": 3250.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3250.24, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3250.24, "10th_percentile": 3250.24, "90th_percentile": 3250.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1625.12, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1625.12, "10th_percentile": 1625.12, "90th_percentile": 1625.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1895.97, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1895.97, "10th_percentile": 1895.97, "90th_percentile": 1895.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 3120.23, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3120.23, "10th_percentile": 3120.23, "90th_percentile": 3120.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 774.64, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 774.64, "10th_percentile": 774.64, "90th_percentile": 774.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2860.21, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2860.21, "10th_percentile": 2860.21, "90th_percentile": 2860.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1700.96, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1700.96, "10th_percentile": 1700.96, "90th_percentile": 1700.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5417.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5417.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 5417.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2222.62, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2222.62, "10th_percentile": 2222.62, "90th_percentile": 2222.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2225.33, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2225.33, "10th_percentile": 2225.33, "90th_percentile": 2225.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1083.41, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1083.41, "10th_percentile": 1083.41, "90th_percentile": 1083.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 3624.01, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3624.01, "10th_percentile": 3624.01, "90th_percentile": 3624.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 2708.53, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 2708.53, "10th_percentile": 2708.53, "90th_percentile": 2708.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 2719.36, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2719.36, "10th_percentile": 2719.36, "90th_percentile": 2719.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 3109.39, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 3109.39, "10th_percentile": 3109.39, "90th_percentile": 3109.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 4149.47, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 4149.47, "10th_percentile": 4149.47, "90th_percentile": 4149.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2430.09, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2430.09, "10th_percentile": 2430.09, "90th_percentile": 2430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3412.75, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3412.75, "10th_percentile": 3412.75, "90th_percentile": 3412.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1159.25, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1159.25, "10th_percentile": 1159.25, "90th_percentile": 1159.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 4333.65, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 4333.65, "10th_percentile": 4333.65, "90th_percentile": 4333.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2237.25, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2237.25, "10th_percentile": 2237.25, "90th_percentile": 2237.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4333.65, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4333.65, "10th_percentile": 4333.65, "90th_percentile": 4333.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 3479.38, "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": 3479.38, "10th_percentile": 3479.38, "90th_percentile": 3479.38, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3250.24, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3250.24, "10th_percentile": 3250.24, "90th_percentile": 3250.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 4940.36, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 4940.36, "10th_percentile": 4940.36, "90th_percentile": 4940.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 4712.84, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 4712.84, "10th_percentile": 4712.84, "90th_percentile": 4712.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 4165.72, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 4165.72, "10th_percentile": 4165.72, "90th_percentile": 4165.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 2708.53, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2708.53, "10th_percentile": 2708.53, "90th_percentile": 2708.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5417.06, "10th_percentile": 5417.06, "90th_percentile": 5417.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BIVALIRUDIN 250 MG IV SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-29396", "type": "CDM" }, { "code": "J0583", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0562-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 53.29, "maximum": 772.25, "setting": "outpatient", "gross_charge": 772.25, "discounted_cash": 540.57, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $772.25 @ 11.5% = $88.81 due to $0.00 Claim Price", "median_amount": 88.81, "10th_percentile": 88.81, "90th_percentile": 88.81, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $772.25 @ 11.5% = $88.81 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $772.25 @ 11.5% = $88.81 due to $0.00 Claim Price", "median_amount": 88.81, "10th_percentile": 88.81, "90th_percentile": 88.81, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $772.25 @ 11.5% = $88.81 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.5, "10th_percentile": 53.5, "90th_percentile": 53.5, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_algorithm": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges.", "median_amount": 53.5, "10th_percentile": 53.5, "90th_percentile": 53.5, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "ASP DRUGS; Pricing Extension - HB XR PRC - MPFS MULTI 1084134519 & 41371; Note: Multiple pricing methods applied. Paid per Fee Schedule: HB XR MEDICARE ASP DRUG FSC Paid contractual rate, which is the lesser of contractual rate and 100% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 85.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 85.72, "10th_percentile": 85.72, "90th_percentile": 85.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 85.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 85.72, "10th_percentile": 85.72, "90th_percentile": 85.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 85.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 85.72, "10th_percentile": 85.72, "90th_percentile": 85.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 85.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 85.72, "10th_percentile": 85.72, "90th_percentile": 85.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 85.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 85.72, "10th_percentile": 85.72, "90th_percentile": 85.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 85.72, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 85.72, "10th_percentile": 85.72, "90th_percentile": 85.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 463.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 463.35, "10th_percentile": 463.35, "90th_percentile": 463.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 463.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 463.35, "10th_percentile": 463.35, "90th_percentile": 463.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 463.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 463.35, "10th_percentile": 463.35, "90th_percentile": 463.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 772.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 772.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 772.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 772.25, "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 $772.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "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 $772.25 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 772.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $772.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $772.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 772.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $772.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $772.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 772.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 772.25, "10th_percentile": 772.25, "90th_percentile": 772.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 53.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.29, "10th_percentile": 53.29, "90th_percentile": 53.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 53.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.29, "10th_percentile": 53.29, "90th_percentile": 53.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 53.29, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.29, "10th_percentile": 53.29, "90th_percentile": 53.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 317.24, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.24, "10th_percentile": 317.24, "90th_percentile": 317.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 317.24, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.24, "10th_percentile": 317.24, "90th_percentile": 317.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 135.92, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.92, "10th_percentile": 135.92, "90th_percentile": 135.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 135.92, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.92, "10th_percentile": 135.92, "90th_percentile": 135.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 443.27, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 443.27, "10th_percentile": 443.27, "90th_percentile": 443.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 593.86, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 593.86, "10th_percentile": 593.86, "90th_percentile": 593.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 110.43, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 110.43, "10th_percentile": 110.43, "90th_percentile": 110.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 270.29, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 270.29, "10th_percentile": 270.29, "90th_percentile": 270.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 231.68, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 231.68, "10th_percentile": 231.68, "90th_percentile": 231.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 242.49, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 242.49, "10th_percentile": 242.49, "90th_percentile": 242.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 671.86, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 671.86, "10th_percentile": 671.86, "90th_percentile": 671.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 704.29, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 704.29, "10th_percentile": 704.29, "90th_percentile": 704.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 386.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 386.13, "10th_percentile": 386.13, "90th_percentile": 386.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 486.52, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 486.52, "10th_percentile": 486.52, "90th_percentile": 486.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 591.54, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 591.54, "10th_percentile": 591.54, "90th_percentile": 591.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 617.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 617.8, "10th_percentile": 617.8, "90th_percentile": 617.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 617.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 617.8, "10th_percentile": 617.8, "90th_percentile": 617.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 386.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 386.13, "10th_percentile": 386.13, "90th_percentile": 386.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 463.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 463.35, "10th_percentile": 463.35, "90th_percentile": 463.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" } ] } ] }, { "description": "BLADE BEAVER 75L (37-7515)", "code_information": [ { "code": "SUP-156803", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 22.84, "maximum": 159.71, "setting": "outpatient", "gross_charge": 159.71, "discounted_cash": 111.8, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 60.8, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.8, "10th_percentile": 60.8, "90th_percentile": 60.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 60.8, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.8, "10th_percentile": 60.8, "90th_percentile": 60.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 95.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 95.83, "10th_percentile": 95.83, "90th_percentile": 95.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 50.15, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 50.15, "10th_percentile": 50.15, "90th_percentile": 50.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 91.99, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.99, "10th_percentile": 91.99, "90th_percentile": 91.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 22.84, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 22.84, "10th_percentile": 22.84, "90th_percentile": 22.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 47.91, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 47.91, "10th_percentile": 47.91, "90th_percentile": 47.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 55.9, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 55.9, "10th_percentile": 55.9, "90th_percentile": 55.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 84.33, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 84.33, "10th_percentile": 84.33, "90th_percentile": 84.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 65.53, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.53, "10th_percentile": 65.53, "90th_percentile": 65.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 65.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.61, "10th_percentile": 65.61, "90th_percentile": 65.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 71.65, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.65, "10th_percentile": 71.65, "90th_percentile": 71.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "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": "CDH BCBS PPO", "standard_charge_dollar": 71.65, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.65, "10th_percentile": 71.65, "90th_percentile": 71.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 65.61, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.61, "10th_percentile": 65.61, "90th_percentile": 65.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 31.94, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 31.94, "10th_percentile": 31.94, "90th_percentile": 31.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 65.53, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.53, "10th_percentile": 65.53, "90th_percentile": 65.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 159.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $159.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $159.71 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 159.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $159.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $159.71 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 159.71, "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 $159.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "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 $159.71 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 159.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 60.8, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.8, "10th_percentile": 60.8, "90th_percentile": 60.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 60.8, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.8, "10th_percentile": 60.8, "90th_percentile": 60.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 159.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 159.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 159.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 80.17, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.17, "10th_percentile": 80.17, "90th_percentile": 80.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 122.82, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 122.82, "10th_percentile": 122.82, "90th_percentile": 122.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 102.58, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 102.58, "10th_percentile": 102.58, "90th_percentile": 102.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 106.85, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.85, "10th_percentile": 106.85, "90th_percentile": 106.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 145.66, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 145.66, "10th_percentile": 145.66, "90th_percentile": 145.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 127.77, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 127.77, "10th_percentile": 127.77, "90th_percentile": 127.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 91.67, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 91.67, "10th_percentile": 91.67, "90th_percentile": 91.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 95.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 95.83, "10th_percentile": 95.83, "90th_percentile": 95.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 79.86, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.86, "10th_percentile": 79.86, "90th_percentile": 79.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 127.77, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 127.77, "10th_percentile": 127.77, "90th_percentile": 127.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 31.94, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 31.94, "10th_percentile": 31.94, "90th_percentile": 31.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 34.18, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.18, "10th_percentile": 34.18, "90th_percentile": 34.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 138.95, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 138.95, "10th_percentile": 138.95, "90th_percentile": 138.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 65.96, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.96, "10th_percentile": 65.96, "90th_percentile": 65.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 122.34, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 122.34, "10th_percentile": 122.34, "90th_percentile": 122.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 79.86, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 79.86, "10th_percentile": 79.86, "90th_percentile": 79.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 100.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 100.62, "10th_percentile": 100.62, "90th_percentile": 100.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 95.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 95.83, "10th_percentile": 95.83, "90th_percentile": 95.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 95.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 95.83, "10th_percentile": 95.83, "90th_percentile": 95.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 159.71, "10th_percentile": 159.71, "90th_percentile": 159.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLADE LARYNX ANGL 4MM 1884030", "code_information": [ { "code": "SUP-305268", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 722.26, "maximum": 5050.77, "setting": "outpatient", "gross_charge": 5050.77, "discounted_cash": 3535.54, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1922.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1922.83, "10th_percentile": 1922.83, "90th_percentile": 1922.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1922.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1922.83, "10th_percentile": 1922.83, "90th_percentile": 1922.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2265.78, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2265.78, "10th_percentile": 2265.78, "90th_percentile": 2265.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2074.86, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2074.86, "10th_percentile": 2074.86, "90th_percentile": 2074.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1010.15, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1010.15, "10th_percentile": 1010.15, "90th_percentile": 1010.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 5050.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,050.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,050.77 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5050.77, "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 $5,050.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "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 $5,050.77 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 5050.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,050.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,050.77 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 5050.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3030.46, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3030.46, "10th_percentile": 3030.46, "90th_percentile": 3030.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 3030.46, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3030.46, "10th_percentile": 3030.46, "90th_percentile": 3030.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5050.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5050.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 5050.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 1010.15, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 1010.15, "10th_percentile": 1010.15, "90th_percentile": 1010.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 3378.97, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3378.97, "10th_percentile": 3378.97, "90th_percentile": 3378.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 2525.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 2525.39, "10th_percentile": 2525.39, "90th_percentile": 2525.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 2535.49, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2535.49, "10th_percentile": 2535.49, "90th_percentile": 2535.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2899.14, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2899.14, "10th_percentile": 2899.14, "90th_percentile": 2899.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 3868.89, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 3868.89, "10th_percentile": 3868.89, "90th_percentile": 3868.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 3181.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 3181.99, "10th_percentile": 3181.99, "90th_percentile": 3181.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 1080.86, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1080.86, "10th_percentile": 1080.86, "90th_percentile": 1080.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 4040.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 4040.62, "10th_percentile": 4040.62, "90th_percentile": 4040.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 2085.97, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2085.97, "10th_percentile": 2085.97, "90th_percentile": 2085.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4040.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 4040.62, "10th_percentile": 4040.62, "90th_percentile": 4040.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 3244.11, "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": 3244.11, "10th_percentile": 3244.11, "90th_percentile": 3244.11, "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": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 3030.46, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3030.46, "10th_percentile": 3030.46, "90th_percentile": 3030.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 4606.3, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 4606.3, "10th_percentile": 4606.3, "90th_percentile": 4606.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 4394.17, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 4394.17, "10th_percentile": 4394.17, "90th_percentile": 4394.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 3884.04, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 3884.04, "10th_percentile": 3884.04, "90th_percentile": 3884.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 2525.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2525.39, "10th_percentile": 2525.39, "90th_percentile": 2525.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "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": "CDH ADVOCATE IPA", "standard_charge_dollar": 3030.46, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 3030.46, "10th_percentile": 3030.46, "90th_percentile": 3030.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2072.33, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2072.33, "10th_percentile": 2072.33, "90th_percentile": 2072.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 2666.81, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2666.81, "10th_percentile": 2666.81, "90th_percentile": 2666.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2909.24, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2909.24, "10th_percentile": 2909.24, "90th_percentile": 2909.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1585.94, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1585.94, "10th_percentile": 1585.94, "90th_percentile": 1585.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1515.23, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1515.23, "10th_percentile": 1515.23, "90th_percentile": 1515.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 722.26, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 722.26, "10th_percentile": 722.26, "90th_percentile": 722.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1767.77, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1767.77, "10th_percentile": 1767.77, "90th_percentile": 1767.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 2074.86, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2074.86, "10th_percentile": 2074.86, "90th_percentile": 2074.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2072.33, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2072.33, "10th_percentile": 2072.33, "90th_percentile": 2072.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 2265.78, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2265.78, "10th_percentile": 2265.78, "90th_percentile": 2265.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1922.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1922.83, "10th_percentile": 1922.83, "90th_percentile": 1922.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1922.83, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1922.83, "10th_percentile": 1922.83, "90th_percentile": 1922.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5050.77, "10th_percentile": 5050.77, "90th_percentile": 5050.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLADE LIGHTED RETRACTOR BRITEFIELD WAVEGUDE 104015", "code_information": [ { "code": "SUP-353169", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 534.47, "maximum": 3737.52, "setting": "outpatient", "gross_charge": 3737.52, "discounted_cash": 2616.26, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1422.87, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1422.87, "10th_percentile": 1422.87, "90th_percentile": 1422.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1422.87, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1422.87, "10th_percentile": 1422.87, "90th_percentile": 1422.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1422.87, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1422.87, "10th_percentile": 1422.87, "90th_percentile": 1422.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1422.87, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1422.87, "10th_percentile": 1422.87, "90th_percentile": 1422.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2242.51, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2242.51, "10th_percentile": 2242.51, "90th_percentile": 2242.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,737.52 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,737.52 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,737.52 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,737.52 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,737.52 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,737.52 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 1173.58, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 1173.58, "10th_percentile": 1173.58, "90th_percentile": 1173.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 2152.81, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2152.81, "10th_percentile": 2152.81, "90th_percentile": 2152.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 534.47, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 534.47, "10th_percentile": 534.47, "90th_percentile": 534.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 1121.26, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 1121.26, "10th_percentile": 1121.26, "90th_percentile": 1121.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1308.13, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1308.13, "10th_percentile": 1308.13, "90th_percentile": 1308.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1973.41, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1973.41, "10th_percentile": 1973.41, "90th_percentile": 1973.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1533.5, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1533.5, "10th_percentile": 1533.5, "90th_percentile": 1533.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1533.5, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1533.5, "10th_percentile": 1533.5, "90th_percentile": 1533.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 747.5, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 747.5, "10th_percentile": 747.5, "90th_percentile": 747.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1535.37, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1535.37, "10th_percentile": 1535.37, "90th_percentile": 1535.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1535.37, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1535.37, "10th_percentile": 1535.37, "90th_percentile": 1535.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1676.65, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1676.65, "10th_percentile": 1676.65, "90th_percentile": 1676.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1676.65, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1676.65, "10th_percentile": 1676.65, "90th_percentile": 1676.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1543.6, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1543.6, "10th_percentile": 1543.6, "90th_percentile": 1543.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2990.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2990.02, "10th_percentile": 2990.02, "90th_percentile": 2990.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 799.83, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 799.83, "10th_percentile": 799.83, "90th_percentile": 799.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2862.94, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2862.94, "10th_percentile": 2862.94, "90th_percentile": 2862.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1868.76, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1868.76, "10th_percentile": 1868.76, "90th_percentile": 1868.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3737.52, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1876.24, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1876.24, "10th_percentile": 1876.24, "90th_percentile": 1876.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2874.15, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2874.15, "10th_percentile": 2874.15, "90th_percentile": 2874.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2400.61, "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": 2400.61, "10th_percentile": 2400.61, "90th_percentile": 2400.61, "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": "CDH UHC HMO/PPO", "standard_charge_dollar": 2500.4, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2500.4, "10th_percentile": 2500.4, "90th_percentile": 2500.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 3408.62, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 3408.62, "10th_percentile": 3408.62, "90th_percentile": 3408.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 2145.34, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 2145.34, "10th_percentile": 2145.34, "90th_percentile": 2145.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 2242.51, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2242.51, "10th_percentile": 2242.51, "90th_percentile": 2242.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2990.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2990.02, "10th_percentile": 2990.02, "90th_percentile": 2990.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 747.5, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 747.5, "10th_percentile": 747.5, "90th_percentile": 747.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 3251.64, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 3251.64, "10th_percentile": 3251.64, "90th_percentile": 3251.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1868.76, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1868.76, "10th_percentile": 1868.76, "90th_percentile": 1868.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 2354.64, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 2354.64, "10th_percentile": 2354.64, "90th_percentile": 2354.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2242.51, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2242.51, "10th_percentile": 2242.51, "90th_percentile": 2242.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 2242.51, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 2242.51, "10th_percentile": 2242.51, "90th_percentile": 2242.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3737.52, "10th_percentile": 3737.52, "90th_percentile": 3737.52, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLADE SHAVER CURVED CONCAVE FULL RAD 3.5 7210980", "code_information": [ { "code": "SUP-166275", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 129.48, "maximum": 905.46, "setting": "outpatient", "gross_charge": 905.46, "discounted_cash": 633.82, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 543.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 543.28, "10th_percentile": 543.28, "90th_percentile": 543.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 406.19, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 406.19, "10th_percentile": 406.19, "90th_percentile": 406.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 371.96, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.96, "10th_percentile": 371.96, "90th_percentile": 371.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 181.09, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 181.09, "10th_percentile": 181.09, "90th_percentile": 181.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 371.51, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.51, "10th_percentile": 371.51, "90th_percentile": 371.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 905.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $905.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $905.46 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 905.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $905.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $905.46 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 905.46, "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 $905.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "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 $905.46 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 905.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 344.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.71, "10th_percentile": 344.71, "90th_percentile": 344.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 344.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.71, "10th_percentile": 344.71, "90th_percentile": 344.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 478.08, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 478.08, "10th_percentile": 478.08, "90th_percentile": 478.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 521.54, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 521.54, "10th_percentile": 521.54, "90th_percentile": 521.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 284.31, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 284.31, "10th_percentile": 284.31, "90th_percentile": 284.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 271.64, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 271.64, "10th_percentile": 271.64, "90th_percentile": 271.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 129.48, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 129.48, "10th_percentile": 129.48, "90th_percentile": 129.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 316.91, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 316.91, "10th_percentile": 316.91, "90th_percentile": 316.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 905.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 905.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 905.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 454.54, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 454.54, "10th_percentile": 454.54, "90th_percentile": 454.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 696.3, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 696.3, "10th_percentile": 696.3, "90th_percentile": 696.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 581.58, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 581.58, "10th_percentile": 581.58, "90th_percentile": 581.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 605.75, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 605.75, "10th_percentile": 605.75, "90th_percentile": 605.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 825.78, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 825.78, "10th_percentile": 825.78, "90th_percentile": 825.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 724.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 724.37, "10th_percentile": 724.37, "90th_percentile": 724.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 371.96, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.96, "10th_percentile": 371.96, "90th_percentile": 371.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 519.73, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 519.73, "10th_percentile": 519.73, "90th_percentile": 519.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 543.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 543.28, "10th_percentile": 543.28, "90th_percentile": 543.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 452.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 452.73, "10th_percentile": 452.73, "90th_percentile": 452.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 724.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 724.37, "10th_percentile": 724.37, "90th_percentile": 724.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 371.51, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.51, "10th_percentile": 371.51, "90th_percentile": 371.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 181.09, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 181.09, "10th_percentile": 181.09, "90th_percentile": 181.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 193.77, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 193.77, "10th_percentile": 193.77, "90th_percentile": 193.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 787.75, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 787.75, "10th_percentile": 787.75, "90th_percentile": 787.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 373.95, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 373.95, "10th_percentile": 373.95, "90th_percentile": 373.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 693.58, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 693.58, "10th_percentile": 693.58, "90th_percentile": 693.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 452.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 452.73, "10th_percentile": 452.73, "90th_percentile": 452.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 570.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 570.44, "10th_percentile": 570.44, "90th_percentile": 570.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 406.19, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 406.19, "10th_percentile": 406.19, "90th_percentile": 406.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 543.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 543.28, "10th_percentile": 543.28, "90th_percentile": 543.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 543.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 543.28, "10th_percentile": 543.28, "90th_percentile": 543.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 344.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.71, "10th_percentile": 344.71, "90th_percentile": 344.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 344.71, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.71, "10th_percentile": 344.71, "90th_percentile": 344.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 905.46, "10th_percentile": 905.46, "90th_percentile": 905.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLANKET UNDRBYD BAIR HGGR PED", "code_information": [ { "code": "SUP-7305", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 42.79, "maximum": 299.25, "setting": "outpatient", "gross_charge": 299.25, "discounted_cash": 209.47, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 188.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 188.53, "10th_percentile": 188.53, "90th_percentile": 188.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 149.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 149.63, "10th_percentile": 149.63, "90th_percentile": 149.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 239.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 239.4, "10th_percentile": 239.4, "90th_percentile": 239.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 150.22, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.22, "10th_percentile": 150.22, "90th_percentile": 150.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 272.92, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 272.92, "10th_percentile": 272.92, "90th_percentile": 272.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 171.77, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 171.77, "10th_percentile": 171.77, "90th_percentile": 171.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 179.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 179.55, "10th_percentile": 179.55, "90th_percentile": 179.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 192.21, "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": 192.21, "10th_percentile": 192.21, "90th_percentile": 192.21, "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": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 230.12, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 230.12, "10th_percentile": 230.12, "90th_percentile": 230.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 122.93, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.93, "10th_percentile": 122.93, "90th_percentile": 122.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 59.85, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 59.85, "10th_percentile": 59.85, "90th_percentile": 59.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 134.24, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.24, "10th_percentile": 134.24, "90th_percentile": 134.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 229.23, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 229.23, "10th_percentile": 229.23, "90th_percentile": 229.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 260.35, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 260.35, "10th_percentile": 260.35, "90th_percentile": 260.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 64.04, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.04, "10th_percentile": 64.04, "90th_percentile": 64.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 149.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.63, "10th_percentile": 149.63, "90th_percentile": 149.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 239.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 239.4, "10th_percentile": 239.4, "90th_percentile": 239.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 122.78, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.78, "10th_percentile": 122.78, "90th_percentile": 122.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 299.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 299.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 299.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 123.59, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.59, "10th_percentile": 123.59, "90th_percentile": 123.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 200.2, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 200.2, "10th_percentile": 200.2, "90th_percentile": 200.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 179.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 179.55, "10th_percentile": 179.55, "90th_percentile": 179.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 179.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 179.55, "10th_percentile": 179.55, "90th_percentile": 179.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 89.78, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 89.78, "10th_percentile": 89.78, "90th_percentile": 89.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 42.79, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 42.79, "10th_percentile": 42.79, "90th_percentile": 42.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 158.0, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.0, "10th_percentile": 158.0, "90th_percentile": 158.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 93.96, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 93.96, "10th_percentile": 93.96, "90th_percentile": 93.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 104.74, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 104.74, "10th_percentile": 104.74, "90th_percentile": 104.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 172.37, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 172.37, "10th_percentile": 172.37, "90th_percentile": 172.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 122.78, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.78, "10th_percentile": 122.78, "90th_percentile": 122.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 179.55, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 179.55, "10th_percentile": 179.55, "90th_percentile": 179.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 122.93, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.93, "10th_percentile": 122.93, "90th_percentile": 122.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 134.24, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.24, "10th_percentile": 134.24, "90th_percentile": 134.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 59.85, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 59.85, "10th_percentile": 59.85, "90th_percentile": 59.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 299.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $299.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $299.25 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 299.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $299.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $299.25 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 299.25, "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 $299.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "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 $299.25 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 299.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 113.92, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.92, "10th_percentile": 113.92, "90th_percentile": 113.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 113.92, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.92, "10th_percentile": 113.92, "90th_percentile": 113.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 113.92, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.92, "10th_percentile": 113.92, "90th_percentile": 113.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 113.92, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.92, "10th_percentile": 113.92, "90th_percentile": 113.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.25, "10th_percentile": 299.25, "90th_percentile": 299.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLDE SCALP SURG BRD PRKR NO 10 STRL DISP W/RETRCT SHLD", "code_information": [ { "code": "SUP-9044708", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 2.59, "maximum": 18.08, "setting": "outpatient", "gross_charge": 18.08, "discounted_cash": 12.66, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.88, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.88, "10th_percentile": 6.88, "90th_percentile": 6.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.88, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.88, "10th_percentile": 6.88, "90th_percentile": 6.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.88, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.88, "10th_percentile": 6.88, "90th_percentile": 6.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.88, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.88, "10th_percentile": 6.88, "90th_percentile": 6.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 10.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 10.85, "10th_percentile": 10.85, "90th_percentile": 10.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 10.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 10.85, "10th_percentile": 10.85, "90th_percentile": 10.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 10.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 10.85, "10th_percentile": 10.85, "90th_percentile": 10.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 18.08, "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 $18.08 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "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 $18.08 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 18.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $18.08 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $18.08 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 18.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $18.08 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $18.08 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 18.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 18.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 18.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 5.68, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 5.68, "10th_percentile": 5.68, "90th_percentile": 5.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 10.41, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.41, "10th_percentile": 10.41, "90th_percentile": 10.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.59, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 2.59, "10th_percentile": 2.59, "90th_percentile": 2.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 5.42, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 5.42, "10th_percentile": 5.42, "90th_percentile": 5.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 6.33, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 6.33, "10th_percentile": 6.33, "90th_percentile": 6.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 9.55, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.55, "10th_percentile": 9.55, "90th_percentile": 9.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.42, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.42, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 3.62, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 3.62, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 7.43, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.43, "10th_percentile": 7.43, "90th_percentile": 7.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 7.43, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.43, "10th_percentile": 7.43, "90th_percentile": 7.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8.11, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.11, "10th_percentile": 8.11, "90th_percentile": 8.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 8.11, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.11, "10th_percentile": 8.11, "90th_percentile": 8.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 10.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 10.85, "10th_percentile": 10.85, "90th_percentile": 10.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 12.1, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.1, "10th_percentile": 12.1, "90th_percentile": 12.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 9.08, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.08, "10th_percentile": 9.08, "90th_percentile": 9.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 16.49, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 16.49, "10th_percentile": 16.49, "90th_percentile": 16.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 11.61, "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": 11.61, "10th_percentile": 11.61, "90th_percentile": 11.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 7.47, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.47, "10th_percentile": 7.47, "90th_percentile": 7.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 14.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 14.46, "10th_percentile": 14.46, "90th_percentile": 14.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 9.04, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 9.04, "10th_percentile": 9.04, "90th_percentile": 9.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 3.87, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.87, "10th_percentile": 3.87, "90th_percentile": 3.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 10.38, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 10.38, "10th_percentile": 10.38, "90th_percentile": 10.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 15.73, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 15.73, "10th_percentile": 15.73, "90th_percentile": 15.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 11.39, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 11.39, "10th_percentile": 11.39, "90th_percentile": 11.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 13.9, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 13.9, "10th_percentile": 13.9, "90th_percentile": 13.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 13.85, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 13.85, "10th_percentile": 13.85, "90th_percentile": 13.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 14.46, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 14.46, "10th_percentile": 14.46, "90th_percentile": 14.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 9.04, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.04, "10th_percentile": 9.04, "90th_percentile": 9.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.08, "10th_percentile": 18.08, "90th_percentile": 18.08, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BLOCK GUIDE DRILL RT STD GDBLOCK-1.8SR", "code_information": [ { "code": "SUP-342625", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 449.21, "maximum": 3141.34, "setting": "outpatient", "gross_charge": 3141.34, "discounted_cash": 2198.94, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1884.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1884.8, "10th_percentile": 1884.8, "90th_percentile": 1884.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1409.21, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1409.21, "10th_percentile": 1409.21, "90th_percentile": 1409.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1290.46, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1290.46, "10th_percentile": 1290.46, "90th_percentile": 1290.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 628.27, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 628.27, "10th_percentile": 628.27, "90th_percentile": 628.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1288.89, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1288.89, "10th_percentile": 1288.89, "90th_percentile": 1288.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,141.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,141.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,141.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,141.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,141.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,141.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1195.91, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1195.91, "10th_percentile": 1195.91, "90th_percentile": 1195.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1195.91, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1195.91, "10th_percentile": 1195.91, "90th_percentile": 1195.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 1658.63, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1658.63, "10th_percentile": 1658.63, "90th_percentile": 1658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 1809.41, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1809.41, "10th_percentile": 1809.41, "90th_percentile": 1809.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 986.38, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 986.38, "10th_percentile": 986.38, "90th_percentile": 986.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 942.4, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 942.4, "10th_percentile": 942.4, "90th_percentile": 942.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 449.21, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 449.21, "10th_percentile": 449.21, "90th_percentile": 449.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 1099.47, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 1099.47, "10th_percentile": 1099.47, "90th_percentile": 1099.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3141.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 1576.95, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1576.95, "10th_percentile": 1576.95, "90th_percentile": 1576.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 2415.69, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 2415.69, "10th_percentile": 2415.69, "90th_percentile": 2415.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 2017.68, "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": 2017.68, "10th_percentile": 2017.68, "90th_percentile": 2017.68, "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": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 2101.56, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2101.56, "10th_percentile": 2101.56, "90th_percentile": 2101.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 2864.9, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 2864.9, "10th_percentile": 2864.9, "90th_percentile": 2864.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2513.07, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 2513.07, "10th_percentile": 2513.07, "90th_percentile": 2513.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 1290.46, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1290.46, "10th_percentile": 1290.46, "90th_percentile": 1290.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 1803.13, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 1803.13, "10th_percentile": 1803.13, "90th_percentile": 1803.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 1884.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1884.8, "10th_percentile": 1884.8, "90th_percentile": 1884.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 1570.67, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1570.67, "10th_percentile": 1570.67, "90th_percentile": 1570.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 2513.07, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 2513.07, "10th_percentile": 2513.07, "90th_percentile": 2513.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1288.89, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1288.89, "10th_percentile": 1288.89, "90th_percentile": 1288.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 628.27, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 628.27, "10th_percentile": 628.27, "90th_percentile": 628.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 672.25, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 672.25, "10th_percentile": 672.25, "90th_percentile": 672.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 2732.97, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 2732.97, "10th_percentile": 2732.97, "90th_percentile": 2732.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 1297.37, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1297.37, "10th_percentile": 1297.37, "90th_percentile": 1297.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 2406.27, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 2406.27, "10th_percentile": 2406.27, "90th_percentile": 2406.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 1570.67, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 1570.67, "10th_percentile": 1570.67, "90th_percentile": 1570.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 1979.04, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 1979.04, "10th_percentile": 1979.04, "90th_percentile": 1979.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 1409.21, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1409.21, "10th_percentile": 1409.21, "90th_percentile": 1409.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1884.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1884.8, "10th_percentile": 1884.8, "90th_percentile": 1884.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 1884.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 1884.8, "10th_percentile": 1884.8, "90th_percentile": 1884.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1195.91, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1195.91, "10th_percentile": 1195.91, "90th_percentile": 1195.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1195.91, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1195.91, "10th_percentile": 1195.91, "90th_percentile": 1195.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3141.34, "10th_percentile": 3141.34, "90th_percentile": 3141.34, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BODY FEM MOD REST STD +30X23MM CONE W/BOLT", "code_information": [ { "code": "SUP-106542", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 2140.4, "maximum": 31020.3, "setting": "outpatient", "gross_charge": 31020.3, "discounted_cash": 21714.21, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 4435.9, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 1005.81, "10th_percentile": 1005.81, "90th_percentile": 1005.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31,020.30 @ 11.5% = $3,567.33 due to $0.00 Claim Price", "median_amount": 3567.33, "10th_percentile": 3567.33, "90th_percentile": 3567.33, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31,020.30 @ 11.5% = $3,567.33 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31,020.30 @ 11.5% = $3,567.33 due to $0.00 Claim Price", "median_amount": 3567.33, "10th_percentile": 3567.33, "90th_percentile": 3567.33, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $31,020.30 @ 11.5% = $3,567.33 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2287.68, "10th_percentile": 2287.68, "90th_percentile": 2287.68, "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": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3443.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3443.25, "10th_percentile": 3443.25, "90th_percentile": 3443.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3443.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3443.25, "10th_percentile": 3443.25, "90th_percentile": 3443.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3443.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3443.25, "10th_percentile": 3443.25, "90th_percentile": 3443.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3443.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3443.25, "10th_percentile": 3443.25, "90th_percentile": 3443.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3443.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3443.25, "10th_percentile": 3443.25, "90th_percentile": 3443.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3443.25, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 3443.25, "10th_percentile": 3443.25, "90th_percentile": 3443.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2140.4, "10th_percentile": 2140.4, "90th_percentile": 2140.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2140.4, "10th_percentile": 2140.4, "90th_percentile": 2140.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 2140.4, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2140.4, "10th_percentile": 2140.4, "90th_percentile": 2140.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 24816.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 24816.24, "10th_percentile": 24816.24, "90th_percentile": 24816.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "CDH CHOICE CARE", "standard_charge_dollar": 23761.55, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 23761.55, "10th_percentile": 23761.55, "90th_percentile": 23761.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 23854.61, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 23854.61, "10th_percentile": 23854.61, "90th_percentile": 23854.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 15510.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15510.15, "10th_percentile": 15510.15, "90th_percentile": 15510.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 28290.51, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 28290.51, "10th_percentile": 28290.51, "90th_percentile": 28290.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 18612.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 18612.18, "10th_percentile": 18612.18, "90th_percentile": 18612.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 19542.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 19542.79, "10th_percentile": 19542.79, "90th_percentile": 19542.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 12743.14, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12743.14, "10th_percentile": 12743.14, "90th_percentile": 12743.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5459.57, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5459.57, "10th_percentile": 5459.57, "90th_percentile": 5459.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 15510.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 15510.15, "10th_percentile": 15510.15, "90th_percentile": 15510.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 6204.06, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 6204.06, "10th_percentile": 6204.06, "90th_percentile": 6204.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 6638.34, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6638.34, "10th_percentile": 6638.34, "90th_percentile": 6638.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 24816.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 24816.24, "10th_percentile": 24816.24, "90th_percentile": 24816.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 12811.38, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4909.96, "10th_percentile": 4909.96, "90th_percentile": 4909.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31020.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 31020.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 9740.37, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 9740.37, "10th_percentile": 9740.37, "90th_percentile": 9740.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 10857.11, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 10857.11, "10th_percentile": 10857.11, "90th_percentile": 10857.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 16378.72, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16378.72, "10th_percentile": 16378.72, "90th_percentile": 16378.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 9306.09, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 9306.09, "10th_percentile": 9306.09, "90th_percentile": 9306.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 17867.69, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17867.69, "10th_percentile": 17867.69, "90th_percentile": 17867.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 18612.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 18612.18, "10th_percentile": 18612.18, "90th_percentile": 18612.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 18612.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 18612.18, "10th_percentile": 18612.18, "90th_percentile": 18612.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 5459.57, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5459.57, "10th_percentile": 5459.57, "90th_percentile": 5459.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 6204.06, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 6204.06, "10th_percentile": 6204.06, "90th_percentile": 6204.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 12743.14, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12743.14, "10th_percentile": 12743.14, "90th_percentile": 12743.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 18612.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 18612.18, "10th_percentile": 18612.18, "90th_percentile": 18612.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 31020.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 31020.3, "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 $31,020.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "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 $31,020.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 31020.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $31,020.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $31,020.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 31020.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $31,020.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $31,020.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 20752.58, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7389.54, "10th_percentile": 7389.54, "90th_percentile": 7389.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 15572.19, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15572.19, "10th_percentile": 15572.19, "90th_percentile": 15572.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 19924.34, "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": 19924.34, "10th_percentile": 19924.34, "90th_percentile": 19924.34, "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": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 26987.66, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 26987.66, "10th_percentile": 26987.66, "90th_percentile": 26987.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 17805.65, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 17805.65, "10th_percentile": 17805.65, "90th_percentile": 17805.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 31020.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 31020.3, "10th_percentile": 31020.3, "90th_percentile": 31020.3, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BRA POST-OP QUEEN", "code_information": [ { "code": "SUP-303408", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 162.85, "maximum": 1138.8, "setting": "outpatient", "gross_charge": 1138.8, "discounted_cash": 797.16, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 510.87, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.87, "10th_percentile": 510.87, "90th_percentile": 510.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 467.82, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.82, "10th_percentile": 467.82, "90th_percentile": 467.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 872.32, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 872.32, "10th_percentile": 872.32, "90th_percentile": 872.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 243.7, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.7, "10th_percentile": 243.7, "90th_percentile": 243.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH THE ALLIANCE", "standard_charge_dollar": 731.45, "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": 731.45, "10th_percentile": 731.45, "90th_percentile": 731.45, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN", "standard_charge_dollar": 1038.59, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 1038.59, "10th_percentile": 1038.59, "90th_percentile": 1038.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 911.04, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 911.04, "10th_percentile": 911.04, "90th_percentile": 911.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 653.67, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 653.67, "10th_percentile": 653.67, "90th_percentile": 653.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 911.04, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 911.04, "10th_percentile": 911.04, "90th_percentile": 911.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 990.76, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 990.76, "10th_percentile": 990.76, "90th_percentile": 990.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 875.74, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 875.74, "10th_percentile": 875.74, "90th_percentile": 875.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 683.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 683.28, "10th_percentile": 683.28, "90th_percentile": 683.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 761.86, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 761.86, "10th_percentile": 761.86, "90th_percentile": 761.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 227.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 227.76, "10th_percentile": 227.76, "90th_percentile": 227.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 467.25, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.25, "10th_percentile": 467.25, "90th_percentile": 467.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 569.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 569.4, "10th_percentile": 569.4, "90th_percentile": 569.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC CORE", "standard_charge_dollar": 571.68, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 571.68, "10th_percentile": 571.68, "90th_percentile": 571.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 569.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 569.4, "10th_percentile": 569.4, "90th_percentile": 569.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1138.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 1138.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1138.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 470.32, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 470.32, "10th_percentile": 470.32, "90th_percentile": 470.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 717.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 717.44, "10th_percentile": 717.44, "90th_percentile": 717.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 162.85, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 162.85, "10th_percentile": 162.85, "90th_percentile": 162.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 398.58, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 398.58, "10th_percentile": 398.58, "90th_percentile": 398.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 341.64, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 341.64, "10th_percentile": 341.64, "90th_percentile": 341.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 655.95, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 655.95, "10th_percentile": 655.95, "90th_percentile": 655.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 357.58, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 357.58, "10th_percentile": 357.58, "90th_percentile": 357.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 601.29, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.29, "10th_percentile": 601.29, "90th_percentile": 601.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 683.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 683.28, "10th_percentile": 683.28, "90th_percentile": 683.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 683.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 683.28, "10th_percentile": 683.28, "90th_percentile": 683.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 510.87, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 510.87, "10th_percentile": 510.87, "90th_percentile": 510.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 227.76, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 227.76, "10th_percentile": 227.76, "90th_percentile": 227.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 467.82, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.82, "10th_percentile": 467.82, "90th_percentile": 467.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 683.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 683.28, "10th_percentile": 683.28, "90th_percentile": 683.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 467.25, "standard_charge_percentage": 41.03, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.25, "10th_percentile": 467.25, "90th_percentile": 467.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.03% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 1138.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,138.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,138.80 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 1138.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,138.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,138.80 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1138.8, "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 $1,138.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "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 $1,138.80 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 1138.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 433.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 433.54, "10th_percentile": 433.54, "90th_percentile": 433.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 433.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 433.54, "10th_percentile": 433.54, "90th_percentile": 433.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 433.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 433.54, "10th_percentile": 433.54, "90th_percentile": 433.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 433.54, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 433.54, "10th_percentile": 433.54, "90th_percentile": 433.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_algorithm": "No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "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": "CDH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1138.8, "10th_percentile": 1138.8, "90th_percentile": 1138.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BRACE WALKING BOOT PROCARE MAXTRAX LARGE AIR COMPONENT 79-95417", "code_information": [ { "code": "SUP-373501", "type": "CDM" }, { "code": "L4361", "type": "HCPCS" }, { "code": "0274", "type": "RC" } ], "standard_charges": [ { "minimum": 45.65, "maximum": 661.59, "setting": "outpatient", "gross_charge": 661.59, "discounted_cash": 463.11, "payers_information": [ { "payer_name": "JOURNEYCARE INC HOSPICE [1275]", "plan_name": "CDH JOURNEYCARE HOSPICE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "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": "CDH HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BCBS MEDICARE ADVANTAGE [1304]", "plan_name": "CDH BLUE CROSS MMAI (MEDICARE)", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $661.59 @ 11.5% = $76.08 due to $0.00 Claim Price", "median_amount": 76.08, "10th_percentile": 76.08, "90th_percentile": 76.08, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $661.59 @ 11.5% = $76.08 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "CDH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $661.59 @ 11.5% = $76.08 due to $0.00 Claim Price", "median_amount": 76.08, "10th_percentile": 76.08, "90th_percentile": 76.08, "count": "0", "methodology": "other", "additional_payer_notes": "APCs; 100% Billed, and; Pricing Extension - CDH HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR CDH; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $661.59 @ 11.5% = $76.08 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB LITTLE COMPANY OF MARY", "standard_charge_algorithm": "No contract line matched", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "CDH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA", "standard_charge_dollar": 349.32, "standard_charge_percentage": 52.8, "standard_charge_algorithm": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 349.32, "10th_percentile": 349.32, "90th_percentile": 349.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA APCN/SP", "standard_charge_dollar": 207.74, "standard_charge_percentage": 31.4, "standard_charge_algorithm": "All Outpatient Services; 31.4% Billed", "median_amount": 207.74, "10th_percentile": 207.74, "90th_percentile": 207.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 31.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA ASA", "standard_charge_dollar": 381.08, "standard_charge_percentage": 57.6, "standard_charge_algorithm": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.08, "10th_percentile": 381.08, "90th_percentile": 381.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 57.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA BP", "standard_charge_dollar": 198.48, "standard_charge_percentage": 30.0, "standard_charge_algorithm": "All Other OP Services; 30% Billed", "median_amount": 198.48, "10th_percentile": 198.48, "90th_percentile": 198.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 30% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA IL PREFERRED", "standard_charge_dollar": 231.56, "standard_charge_percentage": 35.0, "standard_charge_algorithm": "All Outpatient Services; 35% Billed", "median_amount": 231.56, "10th_percentile": 231.56, "90th_percentile": 231.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "CDH AETNA NM EMPLOYEES", "standard_charge_dollar": 94.61, "standard_charge_percentage": 14.3, "standard_charge_algorithm": "All Services; 14.3% Billed", "median_amount": 94.61, "10th_percentile": 94.61, "90th_percentile": 94.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 14.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 271.78, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 271.78, "10th_percentile": 271.78, "90th_percentile": 271.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 116.44, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.44, "10th_percentile": 116.44, "90th_percentile": 116.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS MEDICAID [1612]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 45.65, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.65, "10th_percentile": 45.65, "90th_percentile": 45.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 330.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 330.8, "10th_percentile": 330.8, "90th_percentile": 330.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 506.78, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 506.78, "10th_percentile": 506.78, "90th_percentile": 506.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 141.58, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 141.58, "10th_percentile": 141.58, "90th_percentile": 141.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 529.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed", "median_amount": 529.27, "10th_percentile": 529.27, "90th_percentile": 529.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA BROAD", "standard_charge_dollar": 273.24, "standard_charge_percentage": 41.3, "standard_charge_algorithm": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 273.24, "10th_percentile": 273.24, "90th_percentile": 273.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 41.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "CDH COMPSYCH", "standard_charge_dollar": 529.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Default %; 80% Billed", "median_amount": 529.27, "10th_percentile": 529.27, "90th_percentile": 529.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 80% Billed" }, { "payer_name": "COUNTYCARE IL COOK CO [1607]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 45.65, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.65, "10th_percentile": 45.65, "90th_percentile": 45.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "CDH FIRST HEALTH", "standard_charge_dollar": 508.76, "standard_charge_percentage": 76.9, "standard_charge_algorithm": "All Outpatient Services; 76.9% Billed", "median_amount": 508.76, "10th_percentile": 508.76, "90th_percentile": 508.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 76.9% Billed" }, { "payer_name": "HEALTH ALLIANCE MEDICAID [1310]", "plan_name": "CDH ILLINOIS MEDICAID", "standard_charge_dollar": 45.65, "standard_charge_percentage": 6.9, "standard_charge_algorithm": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.65, "10th_percentile": 45.65, "90th_percentile": 45.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default POC; 6.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH HFN", "standard_charge_dollar": 603.37, "standard_charge_percentage": 91.2, "standard_charge_algorithm": "OP Services; 91.2% Billed", "median_amount": 603.37, "10th_percentile": 603.37, "90th_percentile": 603.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Services; 91.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "CDH HFN NMH TIER ONE", "standard_charge_dollar": 330.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTH SERVICES; 50% Billed", "median_amount": 330.8, "10th_percentile": 330.8, "90th_percentile": 330.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTH SERVICES; 50% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "CDH SEIU HEALTHLINK", "standard_charge_dollar": 416.8, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "Outpatient Services; 63% Billed", "median_amount": 416.8, "10th_percentile": 416.8, "90th_percentile": 416.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 63% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 132.32, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 132.32, "10th_percentile": 132.32, "90th_percentile": 132.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "CDH MAGELLAN BHS", "standard_charge_dollar": 396.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 396.95, "10th_percentile": 396.95, "90th_percentile": 396.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH PHCS/MULTIPLAN", "standard_charge_dollar": 575.58, "standard_charge_percentage": 87.0, "standard_charge_algorithm": "All Services; 87% Billed", "median_amount": 575.58, "10th_percentile": 575.58, "90th_percentile": 575.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 87% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH SAGAMORE HEALTH PPO", "standard_charge_dollar": 379.75, "standard_charge_percentage": 57.4, "standard_charge_algorithm": "OP; 57.4% Billed", "median_amount": 379.75, "10th_percentile": 379.75, "90th_percentile": 379.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 57.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "CDH THE ALLIANCE", "standard_charge_dollar": 424.94, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 424.94, "10th_percentile": 424.94, "90th_percentile": 424.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - 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": "CDH UHC CORE", "standard_charge_dollar": 332.12, "standard_charge_percentage": 50.2, "standard_charge_algorithm": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 332.12, "10th_percentile": 332.12, "90th_percentile": 332.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 50.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC HMO/PPO", "standard_charge_dollar": 442.6, "standard_charge_percentage": 66.9, "standard_charge_algorithm": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.6, "10th_percentile": 442.6, "90th_percentile": 442.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 66.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 271.78, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 271.78, "10th_percentile": 271.78, "90th_percentile": 271.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PPO", "standard_charge_dollar": 116.44, "standard_charge_percentage": 17.6, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.44, "10th_percentile": 116.44, "90th_percentile": 116.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 17.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 132.32, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 132.32, "10th_percentile": 132.32, "90th_percentile": 132.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "CDH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 661.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "CDH NON-CONTRACTED PAYORS", "standard_charge_dollar": 661.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HUMANA BEHAVIORAL [185]", "plan_name": "CDH LIFESYNCH BHS", "standard_charge_dollar": 661.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "DEFAULT; 100% Billed", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "DEFAULT; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB CHS", "standard_charge_dollar": 661.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $661.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $661.59 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": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 661.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $661.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $661.59 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": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 661.59, "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 $661.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "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 $661.59 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 661.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 661.59, "10th_percentile": 661.59, "90th_percentile": 661.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "DREYER MED IPA ADVOCATE [1409]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 396.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 396.95, "10th_percentile": 396.95, "90th_percentile": 396.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "HUMANA HEALTH PLAN [130]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 396.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 396.95, "10th_percentile": 396.95, "90th_percentile": 396.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH ADVOCATE IPA", "standard_charge_dollar": 396.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "All Services; 60% Billed", "median_amount": 396.95, "10th_percentile": 396.95, "90th_percentile": 396.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 60% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 73.44, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 73.44, "10th_percentile": 73.44, "90th_percentile": 73.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 73.44, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 73.44, "10th_percentile": 73.44, "90th_percentile": 73.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 73.44, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 73.44, "10th_percentile": 73.44, "90th_percentile": 73.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 73.44, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 73.44, "10th_percentile": 73.44, "90th_percentile": 73.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 73.44, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 73.44, "10th_percentile": 73.44, "90th_percentile": 73.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "CDH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 73.44, "standard_charge_percentage": 11.1, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 11.1% 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": 73.44, "10th_percentile": 73.44, "90th_percentile": 73.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 11.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "BREASTBINDER L LINED 2XL/L", "code_information": [ { "code": "SUP-300323", "type": "CDM" }, { "code": "27000001", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 66.45, "maximum": 464.71, "setting": "outpatient", "gross_charge": 464.71, "discounted_cash": 325.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 176.92, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.92, "10th_percentile": 176.92, "90th_percentile": 176.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS BLUECHOICE SELECT", "standard_charge_dollar": 176.92, "standard_charge_percentage": 38.07, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.92, "10th_percentile": 176.92, "90th_percentile": 176.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.07% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS HMO", "standard_charge_dollar": 190.9, "standard_charge_percentage": 41.08, "standard_charge_algorithm": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.9, "10th_percentile": 190.9, "90th_percentile": 190.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 41.08% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 464.71, "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 $464.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 464.71, "10th_percentile": 464.71, "90th_percentile": 464.71, "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 $464.71 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": "CDH BCBS PPO", "standard_charge_dollar": 208.47, "standard_charge_percentage": 44.86, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.47, "10th_percentile": 208.47, "90th_percentile": 208.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.86% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH DUPAGE MEDICAL GROUP", "standard_charge_dollar": 92.94, "standard_charge_percentage": 20.0, "standard_charge_algorithm": "OP; 20% Billed", "median_amount": 92.94, "10th_percentile": 92.94, "90th_percentile": 92.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 20% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "CDH HEALTHLAB BLUE CROSS CHOICE", "standard_charge_dollar": 464.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $464.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 464.71, "10th_percentile": 464.71, "90th_percentile": 464.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Default; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $464.71 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": "CDH HEALTHLAB CHS", "standard_charge_dollar": 464.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $464.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 464.71, "10th_percentile": 464.71, "90th_percentile": 464.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other; 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $464.71 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": "CDH HEALTHLAB EHP IPA", "standard_charge_dollar": 464.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other Non-HL; 100% Billed", "median_amount": 464.71, "10th_percentile": 464.71, "90th_percentile": 464.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Non-HL; 100% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "CDH VALUE OPTIONS BHS", "standard_charge_dollar": 232.36, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 232.36, "10th_percentile": 232.36, "90th_percentile": 232.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "CDH CHOICE CARE", "standard_charge_dollar": 355.97, "standard_charge_percentage": 76.6, "standard_charge_algorithm": "Outpatient; 76.6% Billed", "median_amount": 355.97, "10th_percentile": 355.97, "90th_percentile": 355.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 76.6% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "CDH CIGNA ALTERNATIVE", "standard_charge_dollar": 99.45, "standard_charge_percentage": 21.4, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.45, "10th_percentile": 99.45, "90th_percentile": 99.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 21.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amoun